Comprehensive notesSession 2, Pharmacological/Parenteral Therapies, Reduction of Risk Potential

***Use the Decision Tree on every question. Regardless of the question type, you will always determine the TOPIC (step 1) and evaluate the answer choices (step 5). The full DT may not apply well to all questions, like med questions. However, it takes only seconds to check if Assess vs Imp, Maslow, or ABC’s might apply. Stay in the habit of briefly considering each step so the process stays fresh in your mind.

The NCLEX will always give you the trade name as well as the generic name.

Be able to recognize blood transfusion reactions and their causes.

Medications:• The nurse can never change a medication dosage • Instead, the nurse may withhold a medication dosage

In NCLEX World:• You have an order for anything you need!• You can get anything you need in your NCLEX closet!

IV FLUIDS - Know the correct fluids for a given situation. IV Fluids pg. 57

• Isotonic Solutions - same concentrations as our bodily fluids• Hypotonic Solutions - are 'watered down' • Hypertonic Solutions - are far more concentrated

Hetastarch - is a hypertonic solution and is used as a plasma volume expander such that fluids will move into the intravascular space and improve fluid volume status. Hetastarch (Hespan) is a colloid solution. Similar action to Albumin but less expensive. Used to treat some forms of shock, liver failure, and burns.

Prioritization questions for Pharm - who do you see first? Think about the acuity of the client, the action of the medication, as well as the onset, peak, and duration of the meds.

Remember that you are not looking for "right" answers. You are looking for BEST answers! Don’t get distracted by the fact that the answer you were wanting is not there – look for the best answer that represents a correct choice of those you have to work with.

Ask yourself how each answer choice may represent the concept given in the question. Also ask yourself “what concept does this answer represent”? does it make sense for the situation.

Picture the action an answer represents.

Read every word carefully, slow down and do not accept and answer that is ‘almost correct’.

Key Word Tip: "Restlessness" can indicate hypoxemia.

-The phrases ‘Requires intervention’, ‘requires further teaching’, ‘should be concerned’ and similar phrases mean something is WRONG, incorrect or false.

-When a question says the pt is allergic to a med, consider cross allergies. Your med tables will list cross allergies, contraindications, interactions etc. You need to know these!

-#1 most common reason for med non-compliance is side effects

-Know the labs monitored with a med and WHY.

-Know what the labs represent and what high or low values for them would mean to the pt.

-Pay attention to therapeutic levels/ranges for meds. A narrow therapeutic range means less room for error as far as levels go.

-Know side effects, and understand that adverse reactions are more significant. These are listed in the med tables in your book. Know all life-threatening reactions or interactions, why they occur and any treatments listed.

-If you know why a drug is used, how it works and how that relates to the adverse response – you will not need to memorize all that information. Read to understand!

-Study the meds used as you study the illness, disease or problem. Learning about the meds while you read about the illness helps the meds make sense. If you look at a med every time it is mentioned – before you know it, you’ll know the meds! Do this as you review any practice questions/tests you do.

-Know central lines and the complications associated with them.

-when doing med calculations, make SURE you understand if they are asking for each dose, or the total needed for 24 hrs. worth of doses.

-If there is any question of a med allergy, stop the med! You CAN stop a med a pt may be allergic to. You cannot prescribe a med or change the dose.

-Cocaine - is a MAJOR vasoconstrictor and stimulant

Remember the 4 "Gs" - * Garlic* Ginger* Ginkgo* Ginseng> These decrease platelet aggregation/cause or add to a bleeding risk - use any of these herbals w/caution if taking any other meds that prevent clots, or alter bleeding time.

-Watch for pt. or family statements that describe a side effect or complication of a med.

Kava – Has similar activity to benzodiazepines. Used for insomnia or anxiety. It decreases effect of Sinemet which is given to increase dopamine in Parkinsons. (Pg. 137 in RN Course Book)

You MUST know the herbal medications!

-When a pt. is on more than one inhaler or eye drop, it usually DOES matter which one you use first. Know the order taken, and why.

-Diarrhea is an EARLY sign of Digoxin Toxicity ... KNOW LANOXIN!! -The Double-D’s – Dig and diarrhea – think dig toxicity. It may not be that, but always consider it.

-Mag is a DRAG, slowing cellular metabolism. It slows everything from reflexes to breathing.

-For evaluation questions, you must know why the medication is prescribed and the action of the drug. NCLEX will not tell you why it has been prescribed – you need to KNOW why it’s used and apply that to the answers.

-When looking at electrolyte problems, look at assessments and think about why the assessment is made and how it relates to the electrolyte in question.

-Be able to recognize when a med is working

-some meds require labs be drawn before starting them – know these

-when determining priority pts related to meds – consider the acuity of the pts. illness (ABC’s?). When evaluating pt complaints, consider if it is an ‘expected’ side effect, a non-life threatening response, or a life threatening reaction.

-Know what effects or side effects you must educate your pt. about. A true side effect should not be considered ‘expected’.

-Grapefruit juice interactions usually mean the juice increases the action of the med.

(End Session 2)

***Start Session 3, Reduction of Risk Potential, con’t and start Physiological Adaptation

Reductions of Risk Potential, continued

-When looking for pt. most at risk for complications from a procedure, consider the procedure, the pts. history and how their health problem, etc. may be effected by the procedure. -It's a little different than finding the most unstable pt, you are looking for the pt most likely to have a complication from whatever the question is about.

-For any question that you are asked to prioritize pts. to see or follow up on or are most concerned about use the ‘Who do you see first’ strategy. You are looking for the most unstable pt. To do this, consider:

Who is most unstable?

-stable vs unstable (are they having a symptom of their diagnosis or do they just have a diagnosis without active symptoms)-Chronic vs Acute situation-Potential problem vs actual, right here/right now problem-Expected vs Unexpected -Use the ABC’s-compare each pt to the next one and eliminate the more stable pt of each pair

- Usually a confused pt cannot be reasoned with, follow directions or be expected to think rationally or reasonably. Find the answer that best keeps them safe and reduces chance of self harm.

-When considering who needs a private room, think of someone who is infectious, or is at risk to GET an infection.-At risk pts. may have low white counts, chemo, a medication or a disease that causes lowered immunity making them at risk to get an infection and give the infection to their roommate.

-Chest pain on inspiration is different that angina pain. Pleuritic pain like this may mean pneumonia or atelectasis in the lungs. Treatment is pulmonary toilet – cough and deep breathe, breathing exercises.

-Know your ABG’s and what each value represents.

-Review bronchoscopy – complications may be pneumothorax, or bronchospasm

-When considering allergies to dyes, know that it is the iodine in the dye that is related to shellfish allergies. An MRA is an angiography done in MRI. The contrast dye used does not use iodine, it uses gadolinium so shellfish allergies are not an issue. There is a magnet, so no metal allowed.-pacemakers, neuro stimulators, hip replacements, “shrapnel” (metal left in body from war injuries), earrings/piercings etc. cannot go into the giant magnet.

- Know the nursing considerations for tests and procedures. Recognize expected from unexpected responses and the usual care for before the test and after the procedure.

-For I&O calculations, know that 1 Cup=8oz, 30 cc=1 oz- Be aware that if they ask for the intake, any output they mention is a distracter!-Intake is anything that goes in and STAYS in - PO fluids, IV fluids and any irrigation fluids that do not come back out as drainage.

-Always look at the time frame given – 2 hrs post-op has different needs and potential complications than 2 days post op.

-the time line in a question is very important...are they in recovery, or back on the floor? did they just start chemo, or are they weeks into it?-Is this the first dose of med or 2nd week on it? Is it a new colostomy, or older?-consider what would be expected at the given point in the process.

-***NCLEX may not give you the best or most perfect answer – they may not offer you the answer you want to see listed. Evaluate the answers carefully to see if a less-than-perfect answer represents the correct concept you want.

-***Anything that causes a significant fluid shift out of the body can drop the BP very low. This includes things like IV diuretics, paracentesis, thoracentesis, or significant rapid NG drainage or diarrhea. Check the BP!!

-Know chest tubes, p 229

-documentation is only done when everything is good, or normal.

-When giving meds through a NG tube or G-tube, flush before and after everything you do starting with after checking residual. Finish with a flush before resuming tube feeding.

**End Reduction of risk, Begin Physiological Adaptation

-When someone is choking, if they can cough or speak, they have an airway.

-consider the type of surgery or the procedure and the complications that may occur-Do one thing and go home-Never remove any impaled object

-Understand the basic pathophysiology of the problem and now how a med works to treat the problem

-Review how to instill eye and ear drops

-Know the principles of O2 administration

-When looking at who has the most risk factors, practice using a piece of paper as if it was the white board/dry erase board you will have for the exam. Total up the risk factors for each pt.

-Know target lab values in order to determine risk factors or to recognize successful treatment.

-to keep the question clear in your head with select all questions, repeat the question with each answer choice. Use True/False to keep it simple – am I looking for a true statement about this, or a false statement.

-When reviewing meds, diseases, abnormal findings, complications etc. – always focus on something life threatening. Lose of life and limb are nclex priorities.

-When considering Maslow, usually psychosocial things are eliminated. BUT, sometimes things like therapeutic touch or communication ARE the priority. If physical items are wrong, eliminate them and go for an appropriate psych/soc answer.

-Know if a diagnosis is contagious or not. If it is contagious, know the precautions required.

-“Passing the buck” means asking someone else to do something YOU should do, or passing responsibility to someone else. ‘Call the Doc’ may be passing the

buck – is there something appropriate you should assess or do BEFORE calling the health care provider? Consider any nursing action you could or should take before calling. Do not ask family to do something you should do.

-Know newborn normal assessment and complications-Know Spinal cord injuries and the complications, eye injuries and treatment.-Know the significant complications and treatments of surgeries found in your course book.-know labs and what they represent to the body’s functions-Review ABG’s and what each component means

-Review all tests/procedures and know if they require any special prep or post-procedure care. Know the complications that can occur and the symptoms of those complications.

-Look up any word you don’t know and make a note in your book so you see it every time you look at the page!

-calculations/ formulas are found in your book – 30ml= 1 ounce, 8 ounces=1 cup. To change cups to mls, first change cups to ounces, then multiply ounces by 30 to get mls.

-Review CVA’s, intracranial pressure, suctioning to understand care of CVA and preventing increased ICP. Suctioning, vomiting gagging, straining at BM all can increase ICP in CVA, head injuries, intracranial hemorrhage.-When thinking of preventing increased ICP, answers may reflect measures to prevent this like anti-nausea meds, antihypertensives, laxatives, positioning.-Before we give anything PO to a pt who is dysphasic, we must assess their ability to swallow and protect their airway. The 2 most tested things are gag and swallow reflexes. Regardless of their diagnosis, checking gag does raise ICP. We check it once prior to PO, and we don’t need to check it again unless pts condition changes. Testing it too often raises ICP unnecessarily. However - - if the pt cannot swallow, there is NO reason to check the gag!!!! If they can’t swallow and we gag them, they will aspirate!

-Review trachs, endotracheal intubation and ventilator care(p 244), know suctioning-Review chest tubes, pg 229-Know about central lines and their care, what they measure and complications of central lines.-Review NG tubes, and G-tubes pg 232

-Know MI, know angina vs MI *Remember MONA (treatments for MI's)MorphineOxygenNitroglycerinAspirin

-High glucose, DKA pts. are pouring out urine making them dehydrated. Labs will reflect dehydration. When they have been treated successfully, labs will return to normal reflecting rehydration.

-Pain unrelieved by pain meds must be evaluated. If you are wondering if pain is P/soc, look at your other answer choices - if you can correctly eliminate them, then the pain answer is correct.

-When considering pain in a question, don’t get ‘stuck’ on the strategy that it is P/Soc. If pain is the topic, you must address it. No strategy is intended to apply 100% of the time, things are not always ‘black and white’

-Abd trauma: Cullen’s sign – bruising around belly button means retroperitoneal bleed.

-Epi is not given until and unless anaphylaxis is present. Epi p 64, allergic reactions 145,534 epinephrine=adrenalin, produced by adrenal gland

-anticonvulsants ‘numb’ erratic brain signals so they decrease seizures. Because of this effect, anesthesia may need to be reduced.

-Know risk factors for diseases – if they could be found in the nclex exam, they are in your book

-Review Autonomic Dysreflexia – sympathetic nervous system has become over stimulated and is going crazy. P266

-Fluid overloaded pts will have increased HR and BP, decreased Sp Grav, Hct and BUN. They may present with SOB, rales/crackles, JVD. Give diuretics, fluid and Na restrictions, daily wt., monitor lungs, CVP, edema, I&O. p269

-Review DI – often seen in head injuries. With head injuries need to promote drainage, prevent inc. ICP and watch for DI. P 270-Look at its opposite, SIADH – holding on to water/dilutional low Na, seen with lung Ca.

Know electrolyte imbalances, symptoms and complications

-Review Tetralogy of Fallot – 286

-Know your pacers!

-Review shock states. Shock is shock is shock – know treatment of each type.-DIC is a global anticoagulation problem. It is a cascade of events where none of the clotting factors work. The signs may be subtle at first, like bruising and petechia, but you will also see oozing from IV sites, old lab sticks, nosebleeds, blood in the NG and bleeding from where you shaved them earlier.

(End session 3)

**Session 4, Physiological Adaptation, con’t, Basic Care and Comfort, Management of Care

PHYSIOLOGICAL ADAPTATION, con’t NOTES:

-With metastatic breast cancer, watch for hypercalcemia – electrolytes start on p 271

-In some questions, medicating for pain is an option, but there will be something else that is the real priority that you should do first, so always

consider the ‘pain is psychosocial’ strategy. However, some situations like dsg changes for burns are extremely painful, pre-medication is important. When evaluating answers in a situation where pain really IS the topic Be careful not to immediately eliminate the option of medicating them. Once you eliminate the other answers, don’t be afraid to give the med.

-Sometimes age is a distracter, but with children, they are often looking for age appropriate actions or care plans.

- The pain from sickle crisis, burn dressing changes may be considered physical due to their intensity – the question or answer choices will help you decide if it is physical.

-An action CAN be an assessment. Getting an O2 saturation is an action, but it gets information or data – so it is an assessment.

-Know about Addisons – insufficient aldosterone from adrenals. Aldosterone is a steroid, promotes reabsorption of Na and water and is part of the renin-angiotensin system. Steroids also regulate blood sugar, hold back the immune response (making the pt. immunosupressed) and they are needed and released during times of Physical or emotional stress.Addison’s Crises or Adrenal Crises is life threatening and occurs in times of physical/emotional stress when steroid needs cannot be met. P 278

-Remember to review Addisons opposite, Cushings – too much steroid production.

-Spinal Cord Injuries – know the levels of injury and the abilities and disabilities that occur - pg. 266-267... -Know Autonomic Dysreflexia. MEDICAL EMERGENCY- Problem below T1usually caused by excessive sympathetic nervous system stimulation above the level of injury. Usually caused by bladder or bowel distention. Seen after Spinal Shock. Will see hypertension, bradycardia, pounding headache and nasal congestion

-Review heart failure and know the physiology behind right and left failure.

-Know if specific labs are required for a med and why they are important

-Know sickle cell, its treatment and about sickle cell crises. The irregularly shaped red blood cells clog vessels and cause pain. Keeping them well hydrated reduces the chance of blocking vessels. Because the RBC’s are not normal, they carry less O2 so pts. must rest. -For sickle cell: HOP to it – Hydration, O2 and pain relief.

-Cancer treatments are important, radiation treatments are on p 552-Review chemo and when you would see the various side effects occur. For chemo, pay attention to how long they’ve been on it. Early complication is stomatitis – the mouth mucosa cells are rapid growing cells and are affected soon after chemo starts.

Comma, Comma, Comma Strategy • If the answer contains multiple phrases, evaluate each separately• All parts, steps or phrases must be correct for that answer choice to be considered correct

Select All That Apply:• Repeat what you are looking for prior to each answer choice• Approach each choice as True or False

Passing the Buck ~ Referring to another professional• Acceptable when you have eliminated all other answers as something legitimate for you to do in the here and now- If "notify the physician" looks like an attractive option, look at the other choices to ensure that there isn't a better nursing option.

You MUST Know Lab Values for NCLEX – use “normals” in your Kaplan NCLEX bookKnow what the labs MEAN for the patient

-Laryngectomy pts. will need to learn self suctioning, they require humidified O2.

In order to check a gag reflex the patient MUST have a swallow reflex.

Remember on the NCLEX: YOU HAVE THE ORDER.

If you see the word RESTLESS in the stem, think HYPOXIA!!! You can always rule it out – but think of it. If hypoxia is not the problem, consider other reasons for the restlessness like pain, alcohol withdrawl/DTs or even manic.

-When you see answer choices in quotes, think about what the words really mean - what do they convey? What idea or concept are they describing?

When given the age of a client in the stem, consider the developmental stage of that client when selecting your answer.

Diabetes Insipidus pg. 270 in RN Course Book. Also understand it’s opposite, SIADH.

Pulmonary toilet, also called pulmonary hygiene, is a set of methods used to clear mucus and secretions from the airways. Methods used for pulmonary toilet include coughing and deep breathing, suctioning of the airways, chest physiotherapy, blow bottles, incentive spirometers and nasotracheal suction. Bronchoscopy, in which a tube is inserted into the airways so that an examiner can view them, can be used therapeutically as part of pulmonary toilet. While in there, they will suction secretions and may do biopsy of tissue.

NG Tubes:• When given an option, always obtain x-ray for INITIAL verification of placement. Pg 232. After initial x-ray, we check pH of NG returns by aspirating a small amount to confirm it is still in the stomach. pH should be less than 4.-General rule is to check pt before equipment. Exception is any sort of drainage tube. If the question describes symptoms that indicate a drainage

tube may be occluded, you are to check the drainage tube FIRST. This includes foleys or any urinary drainage tube, chest tubes, NG tubes/G-tubes, etc.-G-Tubes: Placed by doc into stomach, sutured in place. This means you do NOT need to check PLACEMENT (it’s in the pt, or on the floor!)But, you DO need to check residuals before any feedings or meds. -By national standard, nurse aides can do gravity tube feedings. However, RN must check placement and residual in NG and residual for G-tube before feeding can be done. Aides may NOT make these assessments and may not irrigate the tubes.

-Smoking - proven risk factor associated with osteoarthritis -> promotes cartilage loss.

Specific Gravity: Remember it as a time 10:10 - 10:30! Value is 1.010 - 1.030

Fat embolism symptoms include: dyspnea, tachycardia, fever, petechial skin rash.

Nutritional questions: the NCLEX does not often state the type of the diet required by the client. First determine the type of diet required by the client, then select the best menu from the answer choices. - Diets like vegan or vegetarian etc, assume they are getting complete nutrition unless the question is specifically about a deficiency with that diet.

***Begin Basic Care and Comfort

-For the arthritis diseases, maintaining joint mobility is the goal – gentle stretching. Avoid activities that cause stress to joints like jumping, hopping. High impact exercises or activities are avoided.

-Long term severe malnutrition and lack of calorie (especially protein) intake leads to low serum albumin because the body will consume the albumin as a protein source for energy needs.

-To evaluate the asthmatics respiratory status, one important tool is the peak flow meter. Measures force of expired air. Pts track their peak flows regularly and frequently. Peak flow meter: 80 to 100% of personal best is normal, 79% to 50% beginning to have exacerbation, under 50% is severe bronchoconstriction and the patient needs treatment with steroids, etc.Asthma p 281

-Remember that fluid shifts may drop BP – when removing fluid from a pt at a rapid rate, check BP

-The treatment of anemia is based on the cause of the anemia. Iron deficiency anemia is treated with iron & Vit C. Microcytic or Pernicious anemia requires B12, hemolytic anemia is treated with transfusions. p 295.

-Time plus distance equals exposure to radiation. Care of implanted radiation 301

- Assistive devices are commonly tested. Know them - they begin on page 318. - “Up with the good, down with the bad” go up stairs with the strong (good) leg first and down stairs with the weak (bad) leg first when using cane, crutches or walker.

- Choose the answer choice that best addresses the stated issue in the question – the correct answer will address the topic or problem.

-High protein meals interfere with the absorption of Sinemet

-Info on pain assessment p 341

-Emboli from bone marrow/fat emboli come from large bone fractures or bone surgeries. Most end up as pulmonary emboli, but some can cause strokes or MI’s. When they go to the lungs this causes significant SOB and is an emergency. ABC’s!

-Traction is all about alignment and pull – pt must not turn or twist, wts must not rest on floor or bed.

-after hip replacements, pt can only flex hip to 45-60 degrees, never more than 90

-‘slight’ and ‘moderate’ usually describe normal or expected findings

-Know about thyroid diseases, and thyroid storm. Know the meds that treat them.

-TPN is high glucose – high urine output is the body’s way of trying to get rid of the glucose. It can only be given through a PICC line or central line.

-Review myasthenia gravis, and myasthenic/cholinergic crises- total loss of voluntary muscle control pg337

-Review multiple sclerosis

-Halo traction has risk of meningitis – know meningitis!

-know about glomerulonephritis and its role in renal function and failure

-Crush injuries and large fractures pose risk of compartment syndrome – be able to recognize this emergency. -5P’s of compartment syndrome:Paresthesias Pulselessness Pallor Pain Paralysis. -Some or all may be present. Watch for SUDDEN increase in pain, SEVERE pain describing this in the setting of crush or large bone break. p346

MANAGEMENT OF CARE NOTES:

Chain of Command:* Vertical chain of command is used when abuse is suspected, legal issues arise, or client safety is a concern. This means you report up the food chain in NURSING when these situations occur. If another department in the hospital or workplace is involved, or needs to be involved in a situation, we do not report to them, we go to the nursing representative ‘above’ us listed in answers.* The vertical chain of command is used in cases of suspected child abuse (all types), client safety issues or legal issues* Failure to report is professional negligence

IN NCLEX LAND: • You have all the time, resources, equipment and staff needed to do the ideal answer. **DO NOT think about the real world of nursing for this test!!!- NCLEX likes for you to stay with your patient

-Focus on the problem that is right here, right now. Potential problems are never as important as a legitimate ‘right now’ problem. There are times they want you to recognize potential problems, but remember actual is the priority over potential.

-You have anything you need o Doctor’s order – you always have an order for the correct answer o A “Magic closet” – never eliminate a correct answer because you don’t have the equipment or staff. You have it if it is something you need to do the best thing.

ASSIGNMENT / DELEGATION: p411

RN = Assessment, Teaching, Nursing Judgments/Evaluations. Only an RN can do these things. Fresh post-ops, immediate recovery period, admissions, transfers, discharges all need RN. Assignments and delegation are based on the license, not experience.

LPN = Stable patient with a predictable outcome• Recognizes abnormal from normal - would notify RN of abnormal finding or assessment information and RN will evaluate. • Knows sterile procedure – does dressing changes

Aide = Standard / unchanging procedures• VS, O2 Stats, assist w/ADL's, etc.-Aide can collect data, RN must evaluate the data. Aide might get the finger stick glucose, but RN evaluates the number.-When looking at pts for assigning staff, the time frame is very important. A surgical pt just back from recovery needs RN skills, the same pt. 2 days post op may be stable and OK for LPN. Look carefully at each pt.

TO ENSURE PATIENT SAFETY:

** Floats: Assign as you would an LPN/LVN **- Avoid unit specific skills & knowledge (like chemo or death or

prognosis/treatment options)

> A float nurse should request an orientation to the unit, to ensure that you, the nurse, are fully competent to care for assigned pts. and provide for patient safety.> RN Skills are transferable, but the transfer RN should perform only skills where competency has been demonstrated. This means an RN can certainly transfer skills like VS, basic assessment skills, recognizing a problem. They are not expected to have unit specific skills.> The transferred RN should be assigned stable pts. with expected or predictable outcomes.

-therapeutic communication applies to all interactions the nurse has – pts, family, or other staff.

-legal issues, informed consent – p402

***Start session 5 MOC cont, Safety and Inf Control

-SVCS – Superior Vena Cava Syndrome – lung cancer tumors can impair or obstruct venous drainage of the head, neck, arms and chest causing edema, swelling, dyspnea, nosebleeds etc.

-pt can withdraw consent at any time!

-When reporting change of condition to family, use therapeutic communication. Give facts in a way that provides information without alarming them. Don’t give you ‘opinion’ or judgement – tell what happened, what we did, how they responded.

-Sexual harassment is frequently tested – do not confront, do not look into the accused past, you must take action-know your policy and follow it exactly.

-When delegating, give specific instructions and guidelines, it may include what to report to you for assessment by you.

-Review proper documentation guidelines for suspected abuse p 595. Remember, they may not give you perfect choices – look for the BEST answer of those given.

-for nclex, we NEVER assess a pt that is not assigned to us! If there is an issue with another nurses pt, as a staff nurse, you would report it to the person ‘above’ you – charge nurse, supervisor, manager – whoever they give you that represents going up the chain of command in nursing. Do not check the pt., do not confront the nurse assigned to the pt.

-Review documentation of med errors, incidents etc p 415

-Temporary or agency nurses are expected to be able to function as full staff. Someone will take a minute to confirm their skill level and if they have the skills needed for a given area, they do not need a light assignment, they do not require a resource person. There is no reason to check on a float, if there was a float available, you would have them.

-when considering which pt needs their meds first, look at the med, and why they need it

-Once you make staff assignments, you do not change them based on staff preferences

-Restraints, either physical or chemical are a last resort. Only used for physically threatening or violent pts. Confused pts need frequent reorientation – you have the time in nclex land.

-Review teaching, p 421. Pt must be ready to learn, you must adjust your teaching to the pts needs, respect fears and adjust teaching plan to meet THEIR needs at that time.

-simple instructions or information may not require a translator. Complex things DO – admissions, teaching, consents, discharges all would need a translator. Demonstrating using the scrub in a shower do not require translator.

-any pt with neuro issue like stroke, head injury etc. with a widened pulse pressure has increased ICP and must be treated immediately. p 263

**End MOC, Start Safety and Inf Control

-For seizure precautions, we no longer use anything as a bite block. We do not insert things in the mouth like airways. Side rails are considered restraints in more facilities, nclex supports this and we use a mat on the floor to protect from injury. Mattress may also be placed on floor. P261

-Goggles are required for droplet prec. If staff needs to wear goggles, the infection is spread by droplets. Prec p 428

-age approp care 205

-Mono – 426 Review the job of the spleen and what happens with mono that the spleen is at increased risk for rupture. Avoid contact sports.

-TB test positive is 10 or more. Immunosupressed pts lack the ability to respond to antigen, so a 5 cm bump may be positive for them. If they are NOT immunosupressed, the 5mm bump is negative. Know everything about TB, exposure, meds and treatments.

-PROM is at risk for infection because the membrane protecting fetus has ruptured leaving an open path for germs to travel up to baby and mom.477, PP infections 501

-pts with difficult behaviors need therapeutic commun to determine reason for negative behavior.

-know lead poisoning

**End session 5

**Session 6, cont Safety/Inf Control, Health Promotion and Maint. and Psych

-Review hazardous materials/spills.

-Know the safety issues with buying used car seats. RN must discharge pt with properly labeled, tagged, approved car seat or supply pt with loaner seat.

-Recognize hazards to children – food, environmental, poisons

-Auto safety is the number one risk for young males

**Start Health Prom. And Maint.

-Erikson is extremely important for the exam…ages and stages throughout the lifespan. Nclex loves Erikson and growth and development P 454

-Play is the work of childhood – 453

-know amniocentesis – pre and post amino needs, complications

-Understand Rh incompatibility, treatment

-Fetal positions are on p479

-Vena cava syndrome – mom is on her back, baby compresses vena cava causing drop in BP and symptoms. Turn mom to L side and keep flat to restore circ.to both mom and baby.

-Late decels mean fetal distress from lack of O2. Give mom high flow O2 to help baby. Remember VEAL CHOP:• Variable = Cord Compression• Early = Head Compression• Acceleration = OK• Late = Placenta Insufficiency

-

-Babies need to be fed frequently to maintain hydration. For breastfeeding moms, increasing intake without increasing frequency of feeding will not help baby rehydrate. Amount of voids and stools indicates hydration, baby is hydrated when output is normal again. Nl outputs 506- Infant NORMALS:•2-3 BM's daily •8 wet diapers daily

-difficulty sleeping may be tested, or may be used as a symptom. You must determine if this is the thing being tested – if so, it is a physical issue. However, in some cases it may just be one of several symptoms or a P/Soc answer choice. You must determine if in a particular situation it is a physical problem or simply an item to be discarded for a more important need or problem. Sleep p 355

-Know normal newborn assessment – 503

-Know hyperbilirubinemia, phototherapy and the complication of encephalopathy 510

-C-Diff is a highly contagious infection that develops with antibiotic use, especially longer term use of IV antibiotics in the elderly. You must eval meds if that option is given to determine if it may be a side effect of anything they are taking before you call it c-diff and get a stool spec. Do 1 thing FIRST. You cannot place this pt with anyone who does not have the infection.

-When dealing with hazmat contamination, find out what has been done BEFORE they come into your facility. Risk of contaminating everything and everyone.

-If risk factors are listed in your book for a disease, you need to know them.

-Post partum hemorrhage is major risk after birth – p 500

-Understand the pathophysiology behind newborn hypoglycemia

-Review care of babies born to addicted moms 513

-Low temp in newborns is cardinal sign of newborn sepsis – cold babies cannot digest food. Medical emergency! P515

-make sure when a pt has multiple symptoms that you think of what the entire group of symptoms may be. Think about the big picture. If you think the symptoms represent an illness or disease or adverse reaction, eliminate answers that only address ONE symptom. However, keep in mind that the question may also give you lots of distracting symptoms or diagnosis, and be asking only about 1 thing. Consider both possibilities. Don’t lock yourself in to an idea and not recognize that you need to change your thought. Do NOT manipulate answers by making up stories to support a wrong theory.

-A saturated peri pad is 100cc’s of blood, 1 saturated pad per hour is hemorrhage!

-nclex views the urge to void, feelings of pressure as a problem to be investigated and NOT expected. Assess the drainage tubing.

-Know the childhood diseases, incubation periods, exposure and precautions required. 426

-Know immunization schedules for all age groups – there are no tricks, you just need to memorize these

-Know landmarks for heart sounds and where the valves are.

***Begin Psychosocial Integrity

-Even though this is about psych, valid physical needs will take priority over P/Soc needs. When deciding if something is physical or P/Soc, if you can’t tell immediately, tell yourself you’ll go back to it if you need to. Do NOT spend a lot of time going back and forth or you will go into a swamp and start making up reasons to call it something. JUST MOVE ON! You can go back if you need to, but chances are it won’t matter either way. It will be correct, or you will eliminate it no matter what label you give it.

-manic pts need food and fluids to maintain their high metabolic needs. They need safety and supervision and low stimulation from the environment. They need limits on things like exercise – they are already in constant motion.

-Know lithium!!!!

-Use therapeutic communication and know specific techniques used for specific psych problems. Ther Comm –p552

-Know alcohol withdrawl, DT’s and when you will see them based on time of last drink. 589

-OCD is an anxiety disorder. 557

-Review all side effects and adverse reactions with psych meds. They are frequently tested. Know at what point you would see what problems based on when the med was started. Know which problems must be treated immediately.

-In most cases, belligerent, agitated pts cannot be ‘reasoned with’. Remove to quiet area with supervision. The problem pt is removed from common areas – we do not ask the unit to revolve around the uncooperative pt.

-Review anxiety states in your book.

-Depression is frequently tested. When assessing depressed pts, think of sleep, appetite, concentration, energy and interest.

-an important need in psych is trust. You must establish trust before you can begin to work effectively with them. This is especially important with depressed pts. Therapeutic tip: Sit down, hush up and listen.

-Drug classifications are important with psych meds. Never just d/c an SSRI

-To understand the meds, know what they do. What does serotonin DO, so how does a serotonin reuptake inhibitor help the depression? Doing this with any med you study will decrease the amount of stuff you need to memorize…read to understand! Yes, it takes some time…so does memorization and it is totally ineffective. Spend the time actually learning and you will carry that information beyond the nclex exam and into your practice as an RN.

-Lithium causes diuresis much like DI. They must drink 2500-3000 ml’s a day to keep hydrated.

-With delusions and hallucinations, acknowledge the feelings it causes the pt but do not acknowledge the delusion itself. Do not invite discussion, explanation or argument about the delusion or hallucination. Provide facts or reinforce reality. P582

-Review schizophrenia 579

-Know the antipsychotic meds, side effects, interactions and adverse reactions. Life threatening reactions will be tested. 102

-pts in rehab are master manipulators. Remember that in psych, we use rules and limit setting to prevent manipulation. We do it gently but firmly. Consistency among staff is key to prevent staff splitting.

-A violent or physically threatening pt is the only pt we don’t stay with

-Assault cycle p586

HEALTH PROMOTION & MAINTENANCE NOTES:

Frothy Sputum = Esoph/Trach (Pg. 181-182)• Serious Situation• Needs immediate treatment -> Surgical

Toddlers should NOT be given peanuts, gum, popcorn, carrots or hotdogs = Choking hazards

PSYCHOSOCIAL NOTES:

THERAPUTIC COMMUNICATION:1.) Respond in feeling tone2.) Provide information3.) Don't ask "why" questions4.) Don't ask "yes/no" questions5.) Don't focus on the nurse6.) Don't explore/probe/prod7.) Don't say, "don't worry"

(Pg. 552 in your book)Depression & Antidepressants:> Be aware of onset, peak, duration and time required to reach therapeutic serum levels for medications> Increased energy is a common response to antidepressant medications> Depressed pt. responds better to activity-based therapy, participating in activities that provide socialization Manic Patients:• Don't play well with others • You need to stay with the patient and provide supervision• Can distract manic patients and toddlersSuicidal Patients:• Be direct• Ask them if they have a plan• It is OK to ask a yes/no question in these situations because we need to find out if they are thinking about possible suicide!

HIPPA always applies

Pain between the shoulder blades: possible MI or triple-A rupture

Potential problems are lower priority than actual problems right now

Compartment syndrome: increased pressure within the fascia, can result in destruction of all tissues within. Seen after crush injuries and too tight casts

When you have answer choices that list vitals or state "vital signs stable", go with the specific vitals

Patient assignments are based ONLY on the patient's needs/acuity

Don't check the gag reflex in someone who lacks swallow reflex due to risk for aspiration if stomach contents come up with the gag

Interpreters are needed for questions or assessments. A simple skill that can be demonstrated doesn't require an interpreter.

Mastectomies, ostomies, and amputations are considered more complex surgeries due to the body image change that accompanies the surgery.

Q Bank- 1300 questions customized test No more than 150 questions per day Greater than 65%

Trainers 1-5 – Need to score 65% or greaterTrainers 6&7 – aim to score greater than 60%

1-800-KAP-TEST

Management of Care: 16-22%Safety and Infection Control: 8-14%Health Promotion and Maintenance: 6-12%Psychosocial Integ: 6-12%Basic Care and comfort: 6-12%Pharm: 13-19%Risk: 10-16%Physiological Adapt: 11-17%

Pain is psychosocial- but remember some "pains are deadly" – chest pain, kidney pain, severe burns,

Don't fall into the Airway Trap: Make sure all answers fit the topic

The word why is the F word of the NCLEX- Its great to eliminate one right away. Ups your odds of getting the question right

Teaching is psychosocial- educate when all is stable and physical needs are met.

Memorize at least one drug from each class with side effects, contraindications, etc.

Comma, comma, comma strategy: if one part of the answer is wrong, the WHOLE answer is wrong

When you see the word BEST. Think you can only do one thing, and one thing ONLY! What is BEST!

ABCs are important-airway is higher priority than breathing which is higher priority than circulation.

Identify the topic of the question as your FIRST step. If you don't understand what the question is asking you are guessing at the correct answer.

Pharm Tip: Study one drug from each class of drugs. TYPICALLY they all act the same. Ex) Beta blockers are avoided in asthmatics.

Make sure when you choose an answer, you dont get into the "What if this happens.....". Dont make up a story about a patient and talk yourself out of a good answer.

Kind of like "BEST" questions......when you see MOST IMPORTANT. You can do one thing and one thing only. What is the MOST IMPORTANT!

NCLEX will always give you both the generic name of meds AND a trade name. Often there is a hint as to what type of med it is in one or the other name.

If there is an answer on the NCLEX it is an option for you to do. You do not need to choose "Call the MD" before you pick an answer.

Any answer choice that gives you additional data is an assessment, even if you are not asking the question and the patient volunteers the information.

NCLEX wants you to focus on what you can do right now that will impact the patient.

You get to do one thing, and one thing only. If you do one thing, you can't do anything else. NCLEX likes the answers that give the greatest impact. Go for the biggest bang for your buck.

In the NCLEX world you never repeat an assessment, and never follow an assessment with another assessment. Once you have an assessment you must implement.

It is appropriate to contact the physician ONLY when you have a life or limb threatening issue. Otherwise calling the doc is passing the buck.

With med questions be sure to look at both the generic and the trade name for clues as to what the med is for. Most med questions are straight up memorization.

The changes in NCLEX as of April 1 are primarily a slightly increased number of application and analysis level questions must be correct to pass. This course is specifically designed to give you LOTS of practice in application & analysis questions so you will be successful!

Readings for tomorrow: Blue/13th edition book: 205-300.

Purple/12/th edition book: 341-399, 465-499

Excessive means an abnormal finding. Moderate is usually an expected finding.

Grapefruit Interaction: # Anxiety: Valium, Buspar, Versed, Halcion

# Depression: Luvox, Zoloft

# Antiarrythmics: Many Ca+ Channel blockers like Cordarone or cardizem, also Quinidine and Amiodarone

# anticoags: Coumadin

# Epilepsy: Tegretol

# many Statins

# many HIV Anti-virals

Class 3

When the question leads you toward a conclusion but doesn't give you enough information to know for sure you must assess to validate that what you suspect is really happening.

Change in BP and pulse are LATE signs of blood loss.

In the NCLEX world, you have whatever room you want whenever you want it.

Remember that all answer choices are equally possible. You actually have the order for the med or treatment. Everything in the question and the answer choices are real.

KNOW YOUR LABS!!

For ABGs…..Remember ROME

R=RespiratoryO=Opposite Direction(As CO2 goes up; pH goes down)M=MetabolicE=Equil(As HCO3 goes up; pH goes up)

Conversion table is on page 143 of book. Add 1cup=8 ounces.

Immediate intervention means you're looking for the MOST abnormal.

If you're looking for effective treatment, you're looking for normal.

With a possible tube malfunction, check the tube first (IV, chest tube, NG, etc.)

Normal CVP is 2 to 8

Documentation is only the correct answer when the question describes normal.

When you can call what is described in the question a name (fluid overload,, late deceleration, hypovolemic shock) then you have an assessment and MUST implement. In NCLEX you never follow an assessment with an assessment.

G-tube meds are essentially oral meds, and order of the meds is not important. Order is important with eye drops and inhalers.

Everything in nursing is clean first, then dirty.

Restlessness = hypoxia

Error in book: croup is an UPPER airway problem, not lower airway

MI care:M-MorphineO=OxygenN=NitroA=ASA

B=Beta Blocker (Mona got a last name recently)

Don't predict an answer choice based on what is in the question. Your answer probably won't be there, and it will throw you off. You're stuck with the answer choices NLCEX gives you. Just consider those answer choices. Remember, the real world doesn't apply to the NCLEX world.

Be careful that you have enough information in the question to give you a full assessment, and not that they're giving you info that MIGHT be a problem. You sometimes need to validate to come to a firm conclusion of what is going on.

laparoscopic procedures b/c of the CO2 floating up and irritates the diaphragm, which causes pain in the opposite shoulder strap area.

CLASS 4

Remember-if you have effective treatment, what you did worked. If what you did worked, you're looking for a NORMAL finding in the answer.

Heart failure: Left (L) is lung complicationsRight is bloating & edema

With select all that apply questions you will always have at least 2 correct and at least one wrong. Never "all of the above"

GarlicGingerGingko-All can increase bleeding

Risk Factors for HTN:-Age-Race-Weight-Diet-Labs (Na, etc)-Family History

VITALS & ABC'S:Resp rate= A or BBP & P=circulationT=not directly an A or B or C

The location of burns is important, NOT distracting information. With face, neck, chest, and abdominal burns you have the risk of inhalation injury.

"Most concerning" means most abnormal

When assessing pain you need a rating (scale of 1 to 10) or description (mild, moderate, severe) to have a full assessment

Diarrhea can be a circulation issue in the elderly and very young because they can get dehydrated very quickly. But when it is an expected side effect of a medication, it is a less important issue than med toxicity.

"Further teaching is necessary" means you are looking for something that is WRONG

Keep in mind that the NCLEX world is different than the real world because it is a national exam. Who can do what in an individual state does not show up here. The Delegation Strategies are the key to answering delegation questions.

DELEGATION STRATEGY RN = assessment, teaching, evaluation LPN= stable pt. predictable outcome Nurs. Assist. = standard unchanging procedures

NCLEX doesn't care what phone numbers you know, they want to know what YOU can do in this situation that will impact the patient.

THERAPEUTIC RESPONSE1. Respond to feeling and tone2. Provide information3. Do not ask "why" questions4. Do not ask "yes / no" questions5. Do not focus on the nurse6. Do not explore (don’t be nosey)7. Do not say, "don't worry"Class #5 TIPS:

**On 'who will you see first' ?'s you will often be able to apply ABC's.

Because ONLY the RN can do assessment & teaching, ONLY the RN can do admissions and discharges. RNs are the ONLY ones to make nursing judgment.

CRITERIA FOR FLOAT NURSE ASSIGNMENT: same as LPN (stable patient with predictable outcome) BUT is OK for the float nurse to do assessment. Avoid unit specific skills (things like chemo, teaching peds patient, etc). NCLEX thinks RNs can do an assessment in ANY setting.

CNAs do unchanging tasks, things that are always done the same way: routine Vitals (not the admission or discharge vitals), blood sugars, O2 sats, enemas, clean catch urines, refill the G-tube feeding, etc.

DOCUMENTATION: be as objective and specific as possible. Avoid opinion & assumption.

DOCUMENTATION HINT #2: NCLEX wants to know what you can do that will impact the patient. Document about the patient before you document to cover yourself legally. On the NCLEX charting is the LAST thing you do! Before you choose to chart make sure there is nothing else that needs to be done!

INTERVENE means you're looking for the WRONG thing to be done in this situation.

AVOID answer choices with the words all, none, always, never.

NCLEX likes you to be specific. If the vital signs are worth mentioning, they should be spelled out. Avoid vital signs stable.

Restraints: every state is different so don't rely on what you do at work. Read the section in the book on restraints.

Your delegations are perfect and never need to be explained nor changed. The exception to that rule is if someone goes home sick, you reassign those patients only.

Patient acuity & initials after your name determine assignments.

Start with least restrictive and move toward more restrictive. Meds & wrist restraints are last ditch efforts. Try something else first when possible.

You must be therapeutic with all persons at all times in NCLEX.

NCLEX really likes "tell me more about it" answers. If you can get more data from the patient, that is good in the NCLEX world.

Select the answer choice that most directly responds to the question.

Remember that state laws do not apply in NCLEX because it is a national exam, and every state has different laws and statutes. DO NOT answer questions based on the way things are done where you dome from. Read the book. Think big picture and perspective.

Pets are lower status than people in NCLEX. Don't be personally offended ;-)

Mastectomies, ostomies, and amputations are surgeries in a different category from all the others because of the complex psychosocial issues (such as grief) IN ADDITION to the usual post-op cares.

A diagnosis is not enough data in most questions to determine who is least stable. Make no assumptions that the patient is having problems or an exacerbation.

Perfect delegation includes: 1)what to do, 2)expected results, 3)what to do if there is a problem.

Play is the work of children and is not limited.

Age is not a distracter when planning care for children. You must think developmentally.

The most common reason for medication non-compliance is side effects.

Lyme Disease is named for the county in Connecticut where it was first identified!

NOW is NCLEX's top priority. ‘Maybe’ & ‘later’ are lower priorities.

Tips from Class 6 "Follow up on" means you are looking for something that is wrong. If the nurse needs to intervene or investigate, you are looking for something wrong. Know Erickson's stages-on page 454 in blue/13th ed book and 110 in purple/12th ed. NCLEX expects everyone to be independent, including children to sleep alone and infants to self calm. A pregnant woman's abdomen can only be palpated if she is supine. When changing position in an NCLEX question, ask yourself if you are trying to prevent or promote something. And when in doubt, put the pregnant lady on her side if you need to change her position. Decelerations (left column) and their cause (right column)V=variable C=cordE=early H=headA=accel O=optimalL=late* P=placenta*if you see the word “after” in the description of the deceleration (decel starts after the contraction starts, the lowest point of the heartrate is after the peak of the contraction, the return to baseline is after the contraction ends) THEY ARE DESCRIBING A LATE DECELERATION. Late decels are always bad.

Know labs and vitals for men, women, & peds Rapid vaginal births and cesarean births can lead to transient crackles because the fluid didn't get squeezed out. If NCLEX is getting at normal they will often use words like "moderate". Words like severe & excessive indicate unexpected findings. Narcotic withdrawal occurs 12 to 24 hours after the last dose of drug. Postpartum checks are done every 15 minutes. Changing the pad is part of the postpartum check. With baby questions, ask yourself if this is a small, medium, or large baby. Small babies are <2500 g (5# 7oz), large are >4000 g (8#13oz), medium are in between. You will often have less than perfect answers, but you are stuck with the answers that are listed. Think of it as getting the best answer present, not a perfect answer. Predicting an answer choice can lead to problems here. Know the difference between HIV+ and AIDS, including the opportunistic infections that move a patient into the AIDS category. You CAN vaccinate a HIV + patient; but some vaccines (live) cannot be given to an AIDS patient Remember: mania & OCD are not voluntary activity. They can't help it. Same with hallucinations & delusions: not imagination (which is voluntary). THERAPEUTIC COMMUNICATION/RESPONSE1. Respond to feeling and tone2. Provide information3. Do not ask "why" questions4. Do not ask "yes / no" questions (except with possible suicide)5. Do not focus on the nurse6. Do not explore/prod7. Do not say, "don't worry" When considering the outcome of an answer choice, ask yourself what would have the greatest impact right now. You get to do one thing and one thing only, then you disappear off the face of the earth. Which one thing has the greatest impact? You need to stay with the patient who is not eating. Make it not an option to not eat. Build a trusting a relationship with them. The NCLEX doesn’t like you to leave your patient alone. With depressed patients you measure sleep, appetite, isolation, interest & energy. Med toxicity in the elderly often manifests as confusion. The medication tables in your text list side effects and nursing

considerations for the types of meds (Unit 3 in Blue book, last section in purple book) Hallucinating or delusional patients: reorient to reality and give facts. Don't argue. Don't feed into the hallucination or delusion Room assignments are based strictly on the basis of contagion: you don’t put someone infectious (dirty) in with someone who is “clean”. You can put 2 of the same diagnosis in the same room. Real world vs NCLEX world: the NCLEX world is perfect world ivory tower nursing. Everything you ever want you have, including access to people like the supervisor, you have meds, equipment, personnel (like whatever foreign language interpreter you want whenever you want them). State statutes and the way you do it at work DO NOT FIT into the NCLEX world. Go by the textbook. All things in the question and in the answer choices are real: you have an order for that med, those people are really there, you have that piece of equipment at your fingertips, etc. You have all the time you need for every patient. You don’t run out of time when assessing patients. Avoid predicting an answer choice. Most often that answer won’t be present, and it will mess with your mind and throw off your test performance. You are always stuck with the 4 answer choices they give you. You might have a less than perfect answer, but choose the best of the answer choices present, EVEN IF IT ISN’T PERFECT. Select all that apply questions: some have 4 answer choices and some have 6. Statistically it takes many more attempts with a select all that apply to prove that it is valid and reliable, so most of the select all that apply questions you’ll see are in the testing process and don’t count towards passing. YOU WILL NOT KNOW WHICH QUESTIONS ARE BEING TESTED. They are not all at the beginning or the end, they are random throughout the exam. Select all that apply questions will have at least 2 correct answers and at least 1 wrong answer. “All of the above” is not an option. Order of removing personal protective equipment (when caring for patients in any type of precautions): 1.gloves2.gown3.goggles4.mask

Drug Endings: -pril ACE Inhibitor-olol Beta Blocker-sartan ARB’s-dipine Calcium Channel Blocker-mycin Aminoglycocide-azole antifungal-cillin penicillin-floxicin - quinolone antibiotics-cycline- tetracyclines-lam benzodiazipines

-pam benzodiazipines-axine SNRI’s-pram SSRI’s-etine SSRi’s

PHARMACOLOGY NOTES:

Medications:• The nurse can never change a medication dosage • Instead, the nurse may withhold a medication dosage

In NCLEX World:• You have an order for anything you need!• You can get anything you need in your NCLEX closet!

IV FLUIDS - Know the correct fluids for a given situation• Isotonic Solutions - same concentrations as our bodily fluids• Hypotonic Solutions - are 'watered down' • Hypertonic Solutions - are far more concentrated

Hetastarch - is a hypertonic solution and is used as a plasma volume expander such that fluids will move into the intravascular space and improve fluid volume status.

Cocaine - is a MAJOR vasoconstrictor

Remember the 4 "Gs" - * Garlic* Ginger* Ginko* Ginseng> These decrease platelet aggregation - use any of these herbals w/caution if taking any other meds that do the same/similar function!

Kava - similar activity to benzodiazepines, produces mild euphoria...decreases effect of Sinemet. (Pg. 137 in RN Course Book)

You MUST know the herbal medications!

Diarrhea is an EARLY sign of Digoxin Toxicity ... KNOW LANOXIN!! (Pg. 113 in RN Course Book)

Drugs with these endings_usually belongs to this class- caine ___ Local anesthetics- cillin____ Antibiotics- dine_____Antiulcer agents (Histamine H2 blockers)- done ____Opioid analgesics- ide______ Oral hypoglycemics- lam _________Anti-anxiety drugs- micin ________Antibiotics

- mide ________Diuretics- mycin _______Antibiotics- nium ________Neuromuscular blocking agents- olol _________Beta-blockers- oxacin _______Antibiotics- pam ________Anti-anxiety drugs- pril _________ACE inhibitors- sone _______Steroids- statin ______Anti-hyperlipidemics- vir _________Anti-virals- zide _______ Diuretics

Grapefruit Juiceamiodarone (Cordarone)astemizole (Hismanal)atorvastatin (Lipitor)budesonide (Entocort)buspirone (BuSpar)cerivastatin (Baycol)cilostazol (Pletal)cisapride (Propulsid, Prepulsid)colchicineeletriptan (Relpax)etoposide (Vepesid)halofantrine (Halfan)lovastatin (Mevacor)mifepristone (Mifeprex)pimozide (Orap)quinidine (Quinaglute,Quinidex)sildenafil (Viagra)simvastatin (Zocor)sirolimus (Rapamune)terfenadine (Seldane)ziprasidone (Geodon)

PHYSIOLOGICAL ADAPTATION NOTES:

Who do you see first?• Stable vs. Unstable strategy• ABC's• Real vs. Potential • Expected vs. Unexpected,

• Chronic vs. Acute• Problems above the belly button - question AIRWAY!• If I can only see ONE person and go home - who will it be?• Will I have a desirable outcome?

Comma, Comma, Comma Strategy -> It’s either ALL CORRECT or not correct at all!• If the answer contains multiple phrases, evaluate each separately• All must be correct for that answer choice to be considered correct itself

Select All That Apply:• Repeat what you are looking for prior to each answer choice• Approach each choice as True or False

Passing the Buck ~ Referring to another professional• Acceptable when you have eliminated all other answers as something legitimate for you to do in the here and now

> If I can only see ONE person and go home - who will it be? After you have made your choice, ask yourself, "Will I have a desirable outcome?"

Confused & Restless Patient:• ? Oxygen deprivation• ? ABC’s

Problems above the belly button - question AIRWAY!

You MUST Know Lab Values for NCLEX – use “normals” in your Kaplan NCLEX book

You Must Know ABG's – (Pg. 218 in RN Course Book)

In order to check a gag reflex the patient MUST have a swallow reflex.

Adrenal Crisis:• LIFE THREATENING!• Not enough Cortisol -> which regulates blood sugar, holds back immune response and is released during stress

Spinal Cord Injuries - pg. 266-267... Know Autonomic Dysreflexia.

Autonomic Dysreflexia:• MEDICAL EMERGENCY! • Usually caused by bladder or bowel distention• Problem below T1• Will see hypertension, bradycardia, pounding headache and nasal congestion

For Sickle Cell – Remember, “Hop To It”!!• Hydrate• Oxygenate• Pain Control

NG Tubes:• When given an option, always obtain x-ray verification of placement

Tetralogy of Fallot:• A congenital heart defect which is classically understood to involve 4 anatomical abnormalities (only 3 are always present)• See your book for more info

SIADH - pg. 270

Diabetes Insipidus - pg. 254-255

Smoking - proven risk factor associated with osteoarthritis -> promotes cartilage loss.

Best way to confirm NG tube placement is X-ray! - Pg. 232Check patient before equipment EXCEPT with tubes!!

Specific Gravity: Remember it as a time 10:10 - 10:30! Value is 1.010 - 1.030

MANAGEMENT OF CARE NOTES:

Chain of Command: Establish a vertical relationship NOT a horizontal one* Vertical chain of command is used when abuse is suspected, legal issues arise, or client safety is a concern.* The vertical chain of command is used in cases of suspected child abuse (all types), client safety issues or legal issues* Failure to report is professional negligence

IN NCLEX LAND: • You have all the time in the world o NCLEX likes for you to stay with your patient o Sit down o Be quiet o Listen

• You have anything you need

o Doctor’s order o A “Magic closet”

• Focus on the “here and now”

ASSIGNMENT / DELEGATION:

RN = Assessment, Teaching, Nursing Judgments/Evaluations

LPN = Stable patient with a predictable outcome• Recognizes abnormal from normal • Knows sterile procedure – does dressing changes

Aide = Standard / unchanging procedures• VS, O2 Stats, assist w/ADL's, etc.

TO ENSURE PATIENT SAFETY:** Floats: Assign as you would an LPN/LVN **

> A float nurse should request an orientation to the unit, to ensure that you, the nurse, are fully competent to care for assigned pts. and provide for patient safety

> Skills are transferable, but the transfer RN should perform only skills where competency has been demonstrated

> The transferred RN should be assigned stable pts. with expected or predictable outcomes.

Standard Precautions Airborne Precautions Droplet Precautions Contact Precautions

Airborne Precautions are designed to reduce the risk or eliminate the airborne transmission of infectious agents. Contact Precautions Microorganisms:1. Antibiotic Resistant Organisms (Methicillin resistant Staphylococcus aureu (MRSA), Extended spectrum beta-lactamase (ESBL), Penicillin resistant Streptococcus pneumoniae (PRSP), Multi-drug resistant Pseudomonas aeruginosa (MDRP))2. Scabies3. Herpes Zoster (Shingles) localized4. Diarrhea, Clostrididum difficile

Droplet Precautions are designed to reduce the risk of droplet transmission of infectious agents.droplets do not remain suspended in the air and generally travel only short distances, usually 3 ft or less.Droplet Contact Precautions Microorganisms:1. Influenza (Flu)2. Viral Respiratory tract infections (adenovirus, parainfluenza, rhinovirus, RSV)3. Streptococcus group A pharyngitis, pneumonia, scarlet fever4. Neisseria meningitidis invasive infections5. H. Influenzae type b invasive infections6. Pertussis7. Rubella8. Mumps Contact Precautions are designed to reduce the risk of transmission of epidemiologically important microorganisms by direct or indirect contact.Contact Precautions Microorganisms:1. Antibiotic Resistant Organisms (Methicillin resistant Staphylococcus aureu (MRSA), Extended spectrum beta-lactamase (ESBL), Penicillin resistant Streptococcus pneumoniae (PRSP), Multi-drug resistant Pseudomonas aeruginosa (MDRP))2. Scabies3. Herpes Zoster (Shingles) localized4. Diarrhea, Clostrididum difficile

Great Site:http://www.med.yale.edu/ynhh/infection/precautions/intro.html

Disease List - Types of Precautions to Use http://www.med.yale.edu/ynhh/infection/dislist/intro.html

Communicable Disease Precautions:http://allnurses.com/nclex-discussion-forum/contact-precautions-you-409406.html Clostridium difficilehttp://www.medicinenet.com/clostridium_difficile_colitis/article.htm

HEALTH PROMOTION & MAINTENANCE NOTES:

Know Erikson’s Stages of Development - pg. 454 NCLEX loves Growth and Development!!!

If you remember nothing else about pregnant women ... remember to put them on their LEFT SIDE!!

Determining Fetal position - pg. 479

Infant NORMALS:•2-3 BM's daily •8 wet diapers daily

Neonatal Vital Signs - pg. 504

Remember VEAL CHOP:• Variable = Cord Compression• Early = Head Compression• Acceleration = OK• Late = Placenta Insufficiency

Frothy Sputum = Esoph/Trach (Pg. 181-182)• Serious Situation• Needs immediate treatment -> Surgical

Toddlers should NOT be given peanuts, gum, popcorn, carrots or hotdogs = Choking hazards

SAFETY & INFECTION CONTROL NOTES:

Safety: • Do the greatest good for the greatest number of people

• The health care provider should not become a second client through exposure to the first client

• The nurse needs to determine if the situation is a threat to the caregiver and those in the ER

• It's important to prevent the spread of contamination

• The type of hazardous material could not be determined by others in the field - it does not make sense to leave where you are to go "out there" to do something the other professionals could not do! It's more important NOW to determine the level of decontamination that was done in the field to ensure safety of the caregiver.

Know Lyme Disease!!! Most common in the Northeast and mid-Atlantic states. Caused by infected deer ticks.

Precautions: You MUST know ALL precautions!

PSYCHOSOCIAL NOTES:

THERAPUTIC COMMUNICATION:1.) Respond in feeling tone2.) Provide information3.) Don't ask "why" questions4.) Don't ask "yes/no" questions5.) Don't focus on the nurse6.) Don't explore7.) Don't say, "don't worry"

(Pg. 552 in your book)

Depression & Antidepressants:

> Be aware of onset, peak, duration and time required to reach therapeutic serum levels for medications

> Increased energy is a common response to antidepressant medications

> A non-verbal clue of suicide intent includes increased energy levels

> Depressed pt. responds better to activity-based therapy, participating in activities that provide socialization

Delusions - DO NOT feed into a patient's delusion

Lithium - Patients taking Lithium need A LOT of fluids ... Dilute Them!

Manic Patients:• Don't play well with others • You need to stay with the patient and provide supervision• Can distract manic patients and toddlers

Suicidal Patients:• Be direct• Ask them if they have a plan• It is OK to ask a yes/no question in these situations because we need to find out if they are thinking about possible suicide!

A blood pressure cuff that’s too narrow can cause a falsely elevated blood pressure reading.

When preparing a single injection for a patient who takes regular and neutral protein Hagedorn insulin, the nurse should draw the regular insulin into the syringe first so that it does not contaminate the regular insulin.

Rhonchi are the rumbling sounds heard on lung auscultation. They are more pronounced during expiration than during inspiration.

Gavage is forced feeding, usually through a gastric tube (a tube passed into the stomach through the mouth).

According to Maslow’s hierarchy of needs, physiologic needs (air, water, food, shelter, sex, activity, and comfort) have the highest priority.

The safest and surest way to verify a patient’s identity is to check the identification band on his wrist.

In the therapeutic environment, the patient’s safety is the primary concern. Fluid oscillation in the tubing of a chest drainage system indicates that the system is

working properly. The nurse should place a patient who has a Sengstaken-Blakemore tube in semi-

Fowler position. The nurse can elicit Trousseau’s sign by occluding the brachial or radial artery. Hand

and finger spasms that occur during occlusion indicate Trousseau’s sign and suggest hypocalcemia.

For blood transfusion in an adult, the appropriate needle size is 16 to 20G. Intractable pain is pain that incapacitates a patient and can’t be relieved by drugs. In an emergency, consent for treatment can be obtained by fax, telephone, or other

telegraphic means. Decibel is the unit of measurement of sound. Informed consent is required for any invasive procedure. A patient who can’t write his name to give consent for treatment must make an X in

the presence of two witnesses, such as a nurse, priest, or physician. The Z-track I.M. injection technique seals the drug deep into the muscle, thereby

minimizing skin irritation and staining. It requires a needle that’s 1" (2.5 cm) or longer.

In the event of fire, the acronym most often used is RACE. (R) Remove the patient. (A) Activate the alarm. (C) Attempt to contain the fire by closing the door. (E) Extinguish the fire if it can be done safely.

A registered nurse should assign a licensed vocational nurse or licensed practical nurse to perform bedside care, such as suctioning and drug administration.

If a patient can’t void, the first nursing action should be bladder palpation to assess for bladder distention.

The patient who uses a cane should carry it on the unaffected side and advance it at the same time as the affected extremity.

To fit a supine patient for crutches, the nurse should measure from the axilla to the sole and add 2" (5 cm) to that measurement.

Assessment begins with the nurse’s first encounter with the patient and continues throughout the patient’s stay. The nurse obtains assessment data through the health history, physical examination, and review of diagnostic studies.

The appropriate needle size for insulin injection is 25G and 5/8" long. Residual urine is urine that remains in the bladder after voiding. The amount of

residual urine is normally 50 to 100 ml. The five stages of the nursing process are assessment, nursing diagnosis, planning,

implementation, and evaluation.

Assessment is the stage of the nursing process in which the nurse continuously collects data to identify a patient’s actual and potential health needs.

Nursing diagnosis is the stage of the nursing process in which the nurse makes a clinical judgment about individual, family, or community responses to actual or potential health problems or life processes.

Planning is the stage of the nursing process in which the nurse assigns priorities to nursing diagnoses, defines short-term and long-term goals and expected outcomes, and establishes the nursing care plan.

Implementation is the stage of the nursing process in which the nurse puts the nursing care plan into action, delegates specific nursing interventions to members of the nursing team, and charts patient responses to nursing interventions.

Evaluation is the stage of the nursing process in which the nurse compares objective and subjective data with the outcome criteria and, if needed, modifies the nursing care plan.

Before administering any “as needed” pain medication, the nurse should ask the patient to indicate the location of the pain.

Jehovah’s Witnesses believe that they shouldn’t receive blood components donated by other people.

To test visual acuity, the nurse should ask the patient to cover each eye separately and to read the eye chart with glasses and without, as appropriate.

When providing oral care for an unconscious patient, to minimize the risk of aspiration, the nurse should position the patient on the side.

During assessment of distance vision, the patient should stand 20′ (6.1 m) from the chart.

For a geriatric patient or one who is extremely ill, the ideal room temperature is 66° to 76° F (18.8° to 24.4° C).

Normal room humidity is 30% to 60%. Hand washing is the single best method of limiting the spread of microorganisms.

Once gloves are removed after routine contact with a patient, hands should be washed for 10 to 15 seconds.

To perform catheterization, the nurse should place a woman in the dorsal recumbent position.

A positive Homans’ sign may indicate thrombophlebitis. Electrolytes in a solution are measured in milliequivalents per liter (mEq/L). A

milliequivalent is the number of milligrams per 100 milliliters of a solution. Metabolism occurs in two phases: anabolism (the constructive phase) and catabolism

(the destructive phase). The basal metabolic rate is the amount of energy needed to maintain essential body

functions. It’s measured when the patient is awake and resting, hasn’t eaten for 14 to 18 hours, and is in a comfortable, warm environment.

The basal metabolic rate is expressed in calories consumed per hour per kilogram of body weight.

Dietary fiber (roughage), which is derived from cellulose, supplies bulk, maintains intestinal motility, and helps to establish regular bowel habits.

Alcohol is metabolized primarily in the liver. Smaller amounts are metabolized by the kidneys and lungs.

Petechiae are tiny, round, purplish red spots that appear on the skin and mucous membranes as a result of intradermal or submucosal hemorrhage.

Purpura is a purple discoloration of the skin that’s caused by blood extravasation. According to the standard precautions recommended by the Centers for Disease

Control and Prevention, the nurse shouldn’t recap needles after use. Most needle sticks result from missed needle recapping.

The nurse administers a drug by I.V. push by using a needle and syringe to deliver the dose directly into a vein, I.V. tubing, or a catheter.

When changing the ties on a tracheostomy tube, the nurse should leave the old ties in place until the new ones are applied.

A nurse should have assistance when changing the ties on a tracheostomy tube. A filter is always used for blood transfusions. A four-point (quad) cane is indicated when a patient needs more stability than a

regular cane can provide. A good way to begin a patient interview is to ask, “What made you seek medical

help?” When caring for any patient, the nurse should follow standard precautions for

handling blood and body fluids. Potassium (K+) is the most abundant cation in intracellular fluid. In the four-point, or alternating, gait, the patient first moves the right crutch followed

by the left foot and then the left crutch followed by the right foot. In the three-point gait, the patient moves two crutches and the affected leg

simultaneously and then moves the unaffected leg. In the two-point gait, the patient moves the right leg and the left crutch

simultaneously and then moves the left leg and the right crutch simultaneously. The vitamin B complex, the water-soluble vitamins that are essential for metabolism,

include thiamine (B1), riboflavin (B2), niacin (B3), pyridoxine (B6), and cyanocobalamin (B12).

When being weighed, an adult patient should be lightly dressed and shoeless. Before taking an adult’s temperature orally, the nurse should ensure that the patient

hasn’t smoked or consumed hot or cold substances in the previous 15 minutes. The nurse shouldn’t take an adult’s temperature rectally if the patient has a cardiac

disorder, anal lesions, or bleeding hemorrhoids or has recently undergone rectal surgery.

In a patient who has a cardiac disorder, measuring temperature rectally may stimulate a vagal response and lead to vasodilation and decreased cardiac output.

When recording pulse amplitude and rhythm, the nurse should use these descriptive measures: +3, bounding pulse (readily palpable and forceful); +2, normal pulse (easily palpable); +1, thready or weak pulse (difficult to detect); and 0, absent pulse (not detectable).

The intraoperative period begins when a patient is transferred to the operating room bed and ends when the patient is admitted to the postanesthesia care unit.

On the morning of surgery, the nurse should ensure that the informed consent form has been signed; that the patient hasn’t taken anything by mouth since midnight, has taken a shower with antimicrobial soap, has had mouth care (without swallowing the water), has removed common jewelry, and has received preoperative medication as prescribed; and that vital signs have been taken and recorded. Artificial limbs and other prostheses are usually removed.

Comfort measures, such as positioning the patient, rubbing the patient’s back, and providing a restful environment, may decrease the patient’s need for analgesics or may enhance their effectiveness.

A drug has three names: generic name, which is used in official publications; trade, or brand, name (such as Tylenol), which is selected by the drug company; and chemical name, which describes the drug’s chemical composition.

To avoid staining the teeth, the patient should take a liquid iron preparation through a straw.

The nurse should use the Z-track method to administer an I.M. injection of iron dextran (Imferon).

An organism may enter the body through the nose, mouth, rectum, urinary or reproductive tract, or skin.

In descending order, the levels of consciousness are alertness, lethargy, stupor, light coma, and deep coma.

To turn a patient by logrolling, the nurse folds the patient’s arms across the chest; extends the patient’s legs and inserts a pillow between them, if needed; places a draw sheet under the patient; and turns the patient by slowly and gently pulling on the draw sheet.

The diaphragm of the stethoscope is used to hear high-pitched sounds, such as breath sounds.

A slight difference in blood pressure (5 to 10 mm Hg) between the right and the left arms is normal.

The nurse should place the blood pressure cuff 1" (2.5 cm) above the antecubital fossa.

When instilling ophthalmic ointments, the nurse should waste the first bead of ointment and then apply the ointment from the inner canthus to the outer canthus.

The nurse should use a leg cuff to measure blood pressure in an obese patient. If a blood pressure cuff is applied too loosely, the reading will be falsely elevated. Ptosis is drooping of the eyelid. A tilt table is useful for a patient with a spinal cord injury, orthostatic hypotension, or

brain damage because it can move the patient gradually from a horizontal to a vertical (upright) position.

To perform venipuncture with the least injury to the vessel, the nurse should turn the bevel upward when the vessel’s lumen is larger than the needle and turn it downward when the lumen is only slightly larger than the needle.

To move a patient to the edge of the bed for transfer, the nurse should follow these steps: Move the patient’s head and shoulders toward the edge of the bed. Move the patient’s feet and legs to the edge of the bed (crescent position). Place both arms well under the patient’s hips, and straighten the back while moving the patient toward the edge of the bed.

When being measured for crutches, a patient should wear shoes. The nurse should attach a restraint to the part of the bed frame that moves with the

head, not to the mattress or side rails. The mist in a mist tent should never become so dense that it obscures clear

visualization of the patient’s respiratory pattern. To administer heparin subcutaneously, the nurse should follow these steps: Clean,

but don’t rub, the site with alcohol. Stretch the skin taut or pick up a well-defined skin fold. Hold the shaft of the needle in a dart position. Insert the needle into the skin at a right (90-degree) angle. Firmly depress the plunger, but don’t aspirate. Leave the needle in place for 10 seconds. Withdraw the needle gently at the angle of insertion. Apply pressure to the injection site with an alcohol pad.

For a sigmoidoscopy, the nurse should place the patient in the knee-chest position or Sims’ position, depending on the physician’s preference.

Maslow’s hierarchy of needs must be met in the following order: physiologic (oxygen, food, water, sex, rest, and comfort), safety and security, love and belonging, self-esteem and recognition, and self-actualization.

When caring for a patient who has a nasogastric tube, the nurse should apply a water-soluble lubricant to the nostril to prevent soreness.

During gastric lavage, a nasogastric tube is inserted, the stomach is flushed, and ingested substances are removed through the tube.

In documenting drainage on a surgical dressing, the nurse should include the size, color, and consistency of the drainage (for example, “10 mm of brown mucoid drainage noted on dressing”).

To elicit Babinski’s reflex, the nurse strokes the sole of the patient’s foot with a moderately sharp object, such as a thumbnail.

A positive Babinski’s reflex is shown by dorsiflexion of the great toe and fanning out of the other toes.

When assessing a patient for bladder distention, the nurse should check the contour of the lower abdomen for a rounded mass above the symphysis pubis.

The best way to prevent pressure ulcers is to reposition the bedridden patient at least every 2 hours.

Antiembolism stockings decompress the superficial blood vessels, reducing the risk of thrombus formation.

In adults, the most convenient veins for venipuncture are the basilic and median cubital veins in the antecubital space.

Two to three hours before beginning a tube feeding, the nurse should aspirate the patient’s stomach contents to verify that gastric emptying is adequate.

People with type O blood are considered universal donors. People with type AB blood are considered universal recipients. Hertz (Hz) is the unit of measurement of sound frequency. Hearing protection is required when the sound intensity exceeds 84 dB. Double

hearing protection is required if it exceeds 104 dB. Prothrombin, a clotting factor, is produced in the liver. If a patient is menstruating when a urine sample is collected, the nurse should note

this on the laboratory request. During lumbar puncture, the nurse must note the initial intracranial pressure and the

color of the cerebrospinal fluid. If a patient can’t cough to provide a sputum sample for culture, a heated aerosol

treatment can be used to help to obtain a sample. If eye ointment and eyedrops must be instilled in the same eye, the eyedrops should

be instilled first. When leaving an isolation room, the nurse should remove her gloves before her mask

because fewer pathogens are on the mask. Skeletal traction, which is applied to a bone with wire pins or tongs, is the most

effective means of traction. The total parenteral nutrition solution should be stored in a refrigerator and removed

30 to 60 minutes before use. Delivery of a chilled solution can cause pain, hypothermia, venous spasm, and venous constriction.

Drugs aren’t routinely injected intramuscularly into edematous tissue because they may not be absorbed.

When caring for a comatose patient, the nurse should explain each action to the patient in a normal voice.

Dentures should be cleaned in a sink that’s lined with a washcloth. A patient should void within 8 hours after surgery. An EEG identifies normal and abnormal brain waves. Samples of feces for ova and parasite tests should be delivered to the laboratory

without delay and without refrigeration. The autonomic nervous system regulates the cardiovascular and respiratory systems. When providing tracheostomy care, the nurse should insert the catheter gently into

the tracheostomy tube. When withdrawing the catheter, the nurse should apply intermittent suction for no more than 15 seconds and use a slight twisting motion.

A low-residue diet includes such foods as roasted chicken, rice, and pasta. A rectal tube shouldn’t be inserted for longer than 20 minutes because it can irritate

the rectal mucosa and cause loss of sphincter control. A patient’s bed bath should proceed in this order: face, neck, arms, hands, chest,

abdomen, back, legs, perineum.

To prevent injury when lifting and moving a patient, the nurse should primarily use the upper leg muscles.

Patient preparation for cholecystography includes ingestion of a contrast medium and a low-fat evening meal.

While an occupied bed is being changed, the patient should be covered with a bath blanket to promote warmth and prevent exposure.

Anticipatory grief is mourning that occurs for an extended time when the patient realizes that death is inevitable.

The following foods can alter the color of the feces: beets (red), cocoa (dark red or brown), licorice (black), spinach (green), and meat protein (dark brown).

When preparing for a skull X-ray, the patient should remove all jewelry and dentures. The fight-or-flight response is a sympathetic nervous system response. Bronchovesicular breath sounds in peripheral lung fields are abnormal and suggest

pneumonia. Wheezing is an abnormal, high-pitched breath sound that’s accentuated on

expiration. Wax or a foreign body in the ear should be flushed out gently by irrigation with warm

saline solution. If a patient complains that his hearing aid is “not working,” the nurse should check

the switch first to see if it’s turned on and then check the batteries. The nurse should grade hyperactive biceps and triceps reflexes as +4. If two eye medications are prescribed for twice-daily instillation, they should be

administered 5 minutes apart. In a postoperative patient, forcing fluids helps prevent constipation. A nurse must provide care in accordance with standards of care established by the

American Nurses Association, state regulations, and facility policy. The kilocalorie (kcal) is a unit of energy measurement that represents the amount of

heat needed to raise the temperature of 1 kilogram of water 1° C. As nutrients move through the body, they undergo ingestion, digestion, absorption,

transport, cell metabolism, and excretion. The body metabolizes alcohol at a fixed rate, regardless of serum concentration. In an alcoholic beverage, proof reflects the percentage of alcohol multiplied by 2. For

example, a 100-proof beverage contains 50% alcohol. A living will is a witnessed document that states a patient’s desire for certain types of

care and treatment. These decisions are based on the patient’s wishes and views on quality of life.

The nurse should flush a peripheral heparin lock every 8 hours (if it wasn’t used during the previous 8 hours) and as needed with normal saline solution to maintain patency.

Quality assurance is a method of determining whether nursing actions and practices meet established standards.

The five rights of medication administration are the right patient, right drug, right dose, right route of administration, and right time.

The evaluation phase of the nursing process is to determine whether nursing interventions have enabled the patient to meet the desired goals.

Outside of the hospital setting, only the sublingual and translingual forms of nitroglycerin should be used to relieve acute anginal attacks.

The implementation phase of the nursing process involves recording the patient’s response to the nursing plan, putting the nursing plan into action, delegating specific nursing interventions, and coordinating the patient’s activities.

The Patient’s Bill of Rights offers patients guidance and protection by stating the responsibilities of the hospital and its staff toward patients and their families during hospitalization.

To minimize omission and distortion of facts, the nurse should record information as soon as it’s gathered.

When assessing a patient’s health history, the nurse should record the current illness chronologically, beginning with the onset of the problem and continuing to the present.

When assessing a patient’s health history, the nurse should record the current illness chronologically, beginning with the onset of the problem and continuing to the present.

A nurse shouldn’t give false assurance to a patient. After receiving preoperative medication, a patient isn’t competent to sign an

informed consent form. When lifting a patient, a nurse uses the weight of her body instead of the strength in

her arms. A nurse may clarify a physician’s explanation about an operation or a procedure to a

patient, but must refer questions about informed consent to the physician. When obtaining a health history from an acutely ill or agitated patient, the nurse

should limit questions to those that provide necessary information. If a chest drainage system line is broken or interrupted, the nurse should clamp the

tube immediately. The nurse shouldn’t use her thumb to take a patient’s pulse rate because the thumb

has a pulse that may be confused with the patient’s pulse. An inspiration and an expiration count as one respiration. Eupnea is normal respiration. During blood pressure measurement, the patient should rest the arm against a

surface. Using muscle strength to hold up the arm may raise the blood pressure. Major, unalterable risk factors for coronary artery disease include heredity, sex, race,

and age. Inspection is the most frequently used assessment technique. Family members of an elderly person in a long-term care facility should transfer some

personal items (such as photographs, a favorite chair, and knickknacks) to the person’s room to provide a comfortable atmosphere.

Pulsus alternans is a regular pulse rhythm with alternating weak and strong beats. It occurs in ventricular enlargement because the stroke volume varies with each heartbeat.

The upper respiratory tract warms and humidifies inspired air and plays a role in taste, smell, and mastication.

Signs of accessory muscle use include shoulder elevation, intercostal muscle retraction, and scalene and sternocleidomastoid muscle use during respiration.

When patients use axillary crutches, their palms should bear the brunt of the weight. Activities of daily living include eating, bathing, dressing, grooming, toileting, and

interacting socially. Normal gait has two phases: the stance phase, in which the patient’s foot rests on

the ground, and the swing phase, in which the patient’s foot moves forward. The phases of mitosis are prophase, metaphase, anaphase, and telophase. The nurse should follow standard precautions in the routine care of all patients. The nurse should use the bell of the stethoscope to listen for venous hums and

cardiac murmurs. The nurse can assess a patient’s general knowledge by asking questions such as

“Who is the president of the United States? Cold packs are applied for the first 20 to 48 hours after an injury; then heat is

applied. During cold application, the pack is applied for 20 minutes and then removed for 10 to 15 minutes to prevent reflex dilation (rebound phenomenon) and frostbite injury.

The pons is located above the medulla and consists of white matter (sensory and motor tracts) and gray matter (reflex centers).

The autonomic nervous system controls the smooth muscles. A correctly written patient goal expresses the desired patient behavior, criteria for

measurement, time frame for achievement, and conditions under which the behavior will occur. It’s developed in collaboration with the patient.

Percussion causes five basic notes: tympany (loud intensity, as heard over a gastric air bubble or puffed out cheek), hyperresonance (very loud, as heard over an emphysematous lung), resonance (loud, as heard over a normal lung), dullness (medium intensity, as heard over the liver or other solid organ), and flatness (soft, as heard over the thigh).

The optic disk is yellowish pink and circular, with a distinct border. A primary disability is caused by a pathologic process. A secondary disability is

caused by inactivity. Nurses are commonly held liable for failing to keep an accurate count of sponges and

other devices during surgery. The best dietary sources of vitamin B6 are liver, kidney, pork, soybeans, corn, and

whole-grain cereals. Iron-rich foods, such as organ meats, nuts, legumes, dried fruit, green leafy

vegetables, eggs, and whole grains, commonly have a low water content. Collaboration is joint communication and decision making between nurses and

physicians. It’s designed to meet patients’ needs by integrating the care regimens of both professions into one comprehensive approach.

Bradycardia is a heart rate of fewer than 60 beats/minute. A nursing diagnosis is a statement of a patient’s actual or potential health problem

that can be resolved, diminished, or otherwise changed by nursing interventions. During the assessment phase of the nursing process, the nurse collects and analyzes

three types of data: health history, physical examination, and laboratory and diagnostic test data.

The patient’s health history consists primarily of subjective data, information that’s supplied by the patient.

The physical examination includes objective data obtained by inspection, palpation, percussion, and auscultation.

When documenting patient care, the nurse should write legibly, use only standard abbreviations, and sign each entry. The nurse should never destroy or attempt to obliterate documentation or leave vacant lines.

Factors that affect body temperature include time of day, age, physical activity, phase of menstrual cycle, and pregnancy.

The most accessible and commonly used artery for measuring a patient’s pulse rate is the radial artery. To take the pulse rate, the artery is compressed against the radius.

In a resting adult, the normal pulse rate is 60 to 100 beats/minute. The rate is slightly faster in women than in men and much faster in children than in adults.

Laboratory test results are an objective form of assessment data. The measurement systems most commonly used in clinical practice are the metric

system, apothecaries’ system, and household system. Before signing an informed consent form, the patient should know whether other

treatment options are available and should understand what will occur during the preoperative, intraoperative, and postoperative phases; the risks involved; and the possible complications. The patient should also have a general idea of the time required from surgery to recovery. In addition, he should have an opportunity to ask questions.

A patient must sign a separate informed consent form for each procedure.

During percussion, the nurse uses quick, sharp tapping of the fingers or hands against body surfaces to produce sounds. This procedure is done to determine the size, shape, position, and density of underlying organs and tissues; elicit tenderness; or assess reflexes.

Ballottement is a form of light palpation involving gentle, repetitive bouncing of tissues against the hand and feeling their rebound.

A foot cradle keeps bed linen off the patient’s feet to prevent skin irritation and breakdown, especially in a patient who has peripheral vascular disease or neuropathy.

Gastric lavage is flushing of the stomach and removal of ingested substances through a nasogastric tube. It’s used to treat poisoning or drug overdose.

During the evaluation step of the nursing process, the nurse assesses the patient’s response to therapy.

Bruits commonly indicate life- or limb-threatening vascular disease. O.U. means each eye. O.D. is the right eye, and O.S. is the left eye. To remove a patient’s artificial eye, the nurse depresses the lower lid. The nurse should use a warm saline solution to clean an artificial eye. A thready pulse is very fine and scarcely perceptible. Axillary temperature is usually 1° F lower than oral temperature. After suctioning a tracheostomy tube, the nurse must document the color, amount,

consistency, and odor of secretions. On a drug prescription, the abbreviation p.c. means that the drug should be

administered after meals. After bladder irrigation, the nurse should document the amount, color, and clarity of

the urine and the presence of clots or sediment. After bladder irrigation, the nurse should document the amount, color, and clarity of

the urine and the presence of clots or sediment. Laws regarding patient self-determination vary from state to state. Therefore, the

nurse must be familiar with the laws of the state in which she works. Gauge is the inside diameter of a needle: the smaller the gauge, the larger the

diameter. An adult normally has 32 permanent teeth. After turning a patient, the nurse should document the position used, the time that

the patient was turned, and the findings of skin assessment. PERRLA is an abbreviation for normal pupil assessment findings: pupils equal, round,

and reactive to light with accommodation. When percussing a patient’s chest for postural drainage, the nurse’s hands should be

cupped. When measuring a patient’s pulse, the nurse should assess its rate, rhythm, quality,

and strength. Before transferring a patient from a bed to a wheelchair, the nurse should push the

wheelchair’s footrests to the sides and lock its wheels. When assessing respirations, the nurse should document their rate, rhythm, depth,

and quality. For a subcutaneous injection, the nurse should use a 5/8" 25G needle. The notation “AA & O × 3” indicates that the patient is awake, alert, and oriented to

person (knows who he is), place (knows where he is), and time (knows the date and time).

Fluid intake includes all fluids taken by mouth, including foods that are liquid at room temperature, such as gelatin, custard, and ice cream; I.V. fluids; and fluids administered in feeding tubes. Fluid output includes urine, vomitus, and drainage (such as from a nasogastric tube or from a wound) as well as blood loss, diarrhea or feces, and perspiration.

After administering an intradermal injection, the nurse shouldn’t massage the area because massage can irritate the site and interfere with results.

When administering an intradermal injection, the nurse should hold the syringe almost flat against the patient’s skin (at about a 15-degree angle), with the bevel up.

To obtain an accurate blood pressure, the nurse should inflate the manometer to 20 to 30 mm Hg above the disappearance of the radial pulse before releasing the cuff pressure.

The nurse should count an irregular pulse for 1 full minute. A patient who is vomiting while lying down should be placed in a lateral position to

prevent aspiration of vomitus. Prophylaxis is disease prevention. Body alignment is achieved when body parts are in proper relation to their natural

position. Trust is the foundation of a nurse-patient relationship. Blood pressure is the force exerted by the circulating volume of blood on the arterial

walls. Malpractice is a professional’s wrongful conduct, improper discharge of duties, or

failure to meet standards of care that causes harm to another. As a general rule, nurses can’t refuse a patient care assignment; however, in most

states, they may refuse to participate in abortions. A nurse can be found negligent if a patient is injured because the nurse failed to

perform a duty that a reasonable and prudent person would perform or because the nurse performed an act that a reasonable and prudent person wouldn’t perform.

States have enacted Good Samaritan laws to encourage professionals to provide medical assistance at the scene of an accident without fear of a lawsuit arising from the assistance. These laws don’t apply to care provided in a health care facility.

A physician should sign verbal and telephone orders within the time established by facility policy, usually 24 hours.

A competent adult has the right to refuse lifesaving medical treatment; however, the individual should be fully informed of the consequences of his refusal.

Although a patient’s health record, or chart, is the health care facility’s physical property, its contents belong to the patient.

Before a patient’s health record can be released to a third party, the patient or the patient’s legal guardian must give written consent.

Under the Controlled Substances Act, every dose of a controlled drug that’s dispensed by the pharmacy must be accounted for, whether the dose was administered to a patient or discarded accidentally.

A nurse can’t perform duties that violate a rule or regulation established by a state licensing board, even if they are authorized by a health care facility or physician.

To minimize interruptions during a patient interview, the nurse should select a private room, preferably one with a door that can be closed.

In categorizing nursing diagnoses, the nurse addresses life-threatening problems first, followed by potentially life-threatening concerns.

The major components of a nursing care plan are outcome criteria (patient goals) and nursing interventions.

Standing orders, or protocols, establish guidelines for treating a specific disease or set of symptoms.

In assessing a patient’s heart, the nurse normally finds the point of maximal impulse at the fifth intercostal space, near the apex.

The S1 heard on auscultation is caused by closure of the mitral and tricuspid valves. To maintain package sterility, the nurse should open a wrapper’s top flap away from

the body, open each side flap by touching only the outer part of the wrapper, and

open the final flap by grasping the turned-down corner and pulling it toward the body.

The nurse shouldn’t dry a patient’s ear canal or remove wax with a cotton-tipped applicator because it may force cerumen against the tympanic membrane.

A patient’s identification bracelet should remain in place until the patient has been discharged from the health care facility and has left the premises.

The Controlled Substances Act designated five categories, or schedules, that classify controlled drugs according to their abuse potential.

Schedule I drugs, such as heroin, have a high abuse potential and have no currently accepted medical use in the United States.

Schedule II drugs, such as morphine, opium, and meperidine (Demerol), have a high abuse potential, but currently have accepted medical uses. Their use may lead to physical or psychological dependence.

Schedule III drugs, such as paregoric and butabarbital (Butisol), have a lower abuse potential than Schedule I or II drugs. Abuse of Schedule III drugs may lead to moderate or low physical or psychological dependence, or both.

Schedule IV drugs, such as chloral hydrate, have a low abuse potential compared with Schedule III drugs.

Schedule V drugs, such as cough syrups that contain codeine, have the lowest abuse potential of the controlled substances.

Activities of daily living are actions that the patient must perform every day to provide self-care and to interact with society.

Testing of the six cardinal fields of gaze evaluates the function of all extraocular muscles and cranial nerves III, IV, and VI.

The six types of heart murmurs are graded from 1 to 6. A grade 6 heart murmur can be heard with the stethoscope slightly raised from the chest.

The most important goal to include in a care plan is the patient’s goal. Fruits are high in fiber and low in protein, and should be omitted from a low-residue

diet. The nurse should use an objective scale to assess and quantify pain. Postoperative

pain varies greatly among individuals. Postmortem care includes cleaning and preparing the deceased patient for family

viewing, arranging transportation to the morgue or funeral home, and determining the disposition of belongings.

The nurse should provide honest answers to the patient’s questions. Milk shouldn’t be included in a clear liquid diet. When caring for an infant, a child, or a confused patient, consistency in nursing

personnel is paramount. The hypothalamus secretes vasopressin and oxytocin, which are stored in the

pituitary gland. The three membranes that enclose the brain and spinal cord are the dura mater, pia

mater, and arachnoid. A nasogastric tube is used to remove fluid and gas from the small intestine

preoperatively or postoperatively. Psychologists, physical therapists, and chiropractors aren’t authorized to write

prescriptions for drugs. The area around a stoma is cleaned with mild soap and water. Vegetables have a high fiber content. The nurse should use a tuberculin syringe to administer a subcutaneous injection of

less than 1 ml. For adults, subcutaneous injections require a 25G 1" needle; for infants, children,

elderly, or very thin patients, they require a 25G to 27G ½" needle.

Before administering a drug, the nurse should identify the patient by checking the identification band and asking the patient to state his name.

To clean the skin before an injection, the nurse uses a sterile alcohol swab to wipe from the center of the site outward in a circular motion.

The nurse should inject heparin deep into subcutaneous tissue at a 90-degree angle (perpendicular to the skin) to prevent skin irritation.

If blood is aspirated into the syringe before an I.M. injection, the nurse should withdraw the needle, prepare another syringe, and repeat the procedure.

The nurse shouldn’t cut the patient’s hair without written consent from the patient or an appropriate relative.

If bleeding occurs after an injection, the nurse should apply pressure until the bleeding stops. If bruising occurs, the nurse should monitor the site for an enlarging hematoma.

When providing hair and scalp care, the nurse should begin combing at the end of the hair and work toward the head.

The frequency of patient hair care depends on the length and texture of the hair, the duration of hospitalization, and the patient’s condition.

Proper function of a hearing aid requires careful handling during insertion and removal, regular cleaning of the ear piece to prevent wax buildup, and prompt replacement of dead batteries.

The hearing aid that’s marked with a blue dot is for the left ear; the one with a red dot is for the right ear.

A hearing aid shouldn’t be exposed to heat or humidity and shouldn’t be immersed in water.

The nurse should instruct the patient to avoid using hair spray while wearing a hearing aid.

The five branches of pharmacology are pharmacokinetics, pharmacodynamics, pharmacotherapeutics, toxicology, and pharmacognosy.

The nurse should remove heel protectors every 8 hours to inspect the foot for signs of skin breakdown.

Heat is applied to promote vasodilation, which reduces pain caused by inflammation. A sutured surgical incision is an example of healing by first intention (healing directly,

without granulation). Healing by secondary intention (healing by granulation) is closure of the wound when

granulation tissue fills the defect and allows reepithelialization to occur, beginning at the wound edges and continuing to the center, until the entire wound is covered.

Keloid formation is an abnormality in healing that’s characterized by overgrowth of scar tissue at the wound site.

The nurse should administer procaine penicillin by deep I.M. injection in the upper outer portion of the buttocks in the adult or in the midlateral thigh in the child. The nurse shouldn’t massage the injection site.

An ascending colostomy drains fluid feces. A descending colostomy drains solid fecal matter.

A folded towel (scrotal bridge) can provide scrotal support for the patient with scrotal edema caused by vasectomy, epididymitis, or orchitis.

When giving an injection to a patient who has a bleeding disorder, the nurse should use a small-gauge needle and apply pressure to the site for 5 minutes after the injection.

Platelets are the smallest and most fragile formed element of the blood and are essential for coagulation.

To insert a nasogastric tube, the nurse instructs the patient to tilt the head back slightly and then inserts the tube. When the nurse feels the tube curving at the

pharynx, the nurse should tell the patient to tilt the head forward to close the trachea and open the esophagus by swallowing. (Sips of water can facilitate this action.)

Families with loved ones in intensive care units report that their four most important needs are to have their questions answered honestly, to be assured that the best possible care is being provided, to know the patient’s prognosis, and to feel that there is hope of recovery.

Double-bind communication occurs when the verbal message contradicts the nonverbal message and the receiver is unsure of which message to respond to.

A nonjudgmental attitude displayed by a nurse shows that she neither approves nor disapproves of the patient.

Target symptoms are those that the patient finds most distressing. A patient should be advised to take aspirin on an empty stomach, with a full glass of

water, and should avoid acidic foods such as coffee, citrus fruits, and cola. For every patient problem, there is a nursing diagnosis; for every nursing diagnosis,

there is a goal; and for every goal, there are interventions designed to make the goal a reality. The keys to answering examination questions correctly are identifying the problem presented, formulating a goal for the problem, and selecting the intervention from the choices provided that will enable the patient to reach that goal.

Fidelity means loyalty and can be shown as a commitment to the profession of nursing and to the patient.

Administering an I.M. injection against the patient’s will and without legal authority is battery.

An example of a third-party payer is an insurance company. The formula for calculating the drops per minute for an I.V. infusion is as follows:

(volume to be infused × drip factor) ÷ time in minutes = drops/minute On-call medication should be given within 5 minutes of the call. Usually, the best method to determine a patient’s cultural or spiritual needs is to ask

him. An incident report or unusual occurrence report isn’t part of a patient’s record, but is

an in-house document that’s used for the purpose of correcting the problem. Critical pathways are a multidisciplinary guideline for patient care. When prioritizing nursing diagnoses, the following hierarchy should be used:

Problems associated with the airway, those concerning breathing, and those related to circulation.

The two nursing diagnoses that have the highest priority that the nurse can assign are Ineffective airway clearance and Ineffective breathing pattern.

A subjective sign that a sitz bath has been effective is the patient’s expression of decreased pain or discomfort.

For the nursing diagnosis Deficient diversional activity to be valid, the patient must state that he’s “bored,” that he has “nothing to do,” or words to that effect.

The most appropriate nursing diagnosis for an individual who doesn’t speak English is Impaired verbal communication related to inability to speak dominant language (English).

The family of a patient who has been diagnosed as hearing impaired should be instructed to face the individual when they speak to him.

Before instilling medication into the ear of a patient who is up to age 3, the nurse should pull the pinna down and back to straighten the eustachian tube.

To prevent injury to the cornea when administering eyedrops, the nurse should waste the first drop and instill the drug in the lower conjunctival sac.

After administering eye ointment, the nurse should twist the medication tube to detach the ointment.

When the nurse removes gloves and a mask, she should remove the gloves first. They are soiled and are likely to contain pathogens.

Crutches should be placed 6" (15.2 cm) in front of the patient and 6" to the side to form a tripod arrangement.

Listening is the most effective communication technique. Before teaching any procedure to a patient, the nurse must assess the patient’s

current knowledge and willingness to learn. Process recording is a method of evaluating one’s communication effectiveness. When feeding an elderly patient, the nurse should limit high-carbohydrate foods

because of the risk of glucose intolerance. When feeding an elderly patient, essential foods should be given first. Passive range of motion maintains joint mobility. Resistive exercises increase muscle

mass. Isometric exercises are performed on an extremity that’s in a cast. A back rub is an example of the gate-control theory of pain. Anything that’s located below the waist is considered unsterile; a sterile field

becomes unsterile when it comes in contact with any unsterile item; a sterile field must be monitored continuously; and a border of 1" (2.5 cm) around a sterile field is considered unsterile.

A “shift to the left” is evident when the number of immature cells (bands) in the blood increases to fight an infection.

A “shift to the right” is evident when the number of mature cells in the blood increases, as seen in advanced liver disease and pernicious anemia.

Before administering preoperative medication, the nurse should ensure that an informed consent form has been signed and attached to the patient’s record.

A nurse should spend no more than 30 minutes per 8-hour shift providing care to a patient who has a radiation implant.

A nurse shouldn’t be assigned to care for more than one patient who has a radiation implant.

Long-handled forceps and a lead-lined container should be available in the room of a patient who has a radiation implant.

Usually, patients who have the same infection and are in strict isolation can share a room.

Diseases that require strict isolation include chickenpox, diphtheria, and viral hemorrhagic fevers such as Marburg disease.

For the patient who abides by Jewish custom, milk and meat shouldn’t be served at the same meal.

Whether the patient can perform a procedure (psychomotor domain of learning) is a better indicator of the effectiveness of patient teaching than whether the patient can simply state the steps involved in the procedure (cognitive domain of learning).

According to Erik Erikson, developmental stages are trust versus mistrust (birth to 18 months), autonomy versus shame and doubt (18 months to age 3), initiative versus guilt (ages 3 to 5), industry versus inferiority (ages 5 to 12), identity versus identity diffusion (ages 12 to 18), intimacy versus isolation (ages 18 to 25), generativity versus stagnation (ages 25 to 60), and ego integrity versus despair (older than age 60).

When communicating with a hearing impaired patient, the nurse should face him. An appropriate nursing intervention for the spouse of a patient who has a serious

incapacitating disease is to help him to mobilize a support system. Hyperpyrexia is extreme elevation in temperature above 106° F (41.1° C). Milk is high in sodium and low in iron. When a patient expresses concern about a health-related issue, before addressing

the concern, the nurse should assess the patient’s level of knowledge. The most effective way to reduce a fever is to administer an antipyretic, which lowers

the temperature set point.

When a patient is ill, it’s essential for the members of his family to maintain communication about his health needs.

Ethnocentrism is the universal belief that one’s way of life is superior to others’. When a nurse is communicating with a patient through an interpreter, the nurse

should speak to the patient and the interpreter. In accordance with the “hot-cold” system used by some Mexicans, Puerto Ricans, and

other Hispanic and Latino groups, most foods, beverages, herbs, and drugs are described as “cold.”

Prejudice is a hostile attitude toward individuals of a particular group. Discrimination is preferential treatment of individuals of a particular group. It’s

usually discussed in a negative sense. Increased gastric motility interferes with the absorption of oral drugs. The three phases of the therapeutic relationship are orientation, working, and

termination. Patients often exhibit resistive and challenging behaviors in the orientation phase of

the therapeutic relationship. Abdominal assessment is performed in the following order: inspection, auscultation,

palpation, and percussion. When measuring blood pressure in a neonate, the nurse should select a cuff that’s no

less than one-half and no more than two-thirds the length of the extremity that’s used.

When administering a drug by Z-track, the nurse shouldn’t use the same needle that was used to draw the drug into the syringe because doing so could stain the skin.

Sites for intradermal injection include the inner arm, the upper chest, and on the back, under the scapula.

When evaluating whether an answer on an examination is correct, the nurse should consider whether the action that’s described promotes autonomy (independence), safety, self-esteem, and a sense of belonging.

When answering a question on the NCLEX examination, the student should consider the cue (the stimulus for a thought) and the inference (the thought) to determine whether the inference is correct. When in doubt, the nurse should select an answer that indicates the need for further information to eliminate ambiguity. For example, the patient complains of chest pain (the stimulus for the thought) and the nurse infers that the patient is having cardiac pain (the thought). In this case, the nurse hasn’t confirmed whether the pain is cardiac. It would be more appropriate to make further assessments.

Veracity is truth and is an essential component of a therapeutic relationship between a health care provider and his patient.

Beneficence is the duty to do no harm and the duty to do good. There’s an obligation in patient care to do no harm and an equal obligation to assist the patient.

Nonmaleficence is the duty to do no harm. Frye’s ABCDE cascade provides a framework for prioritizing care by identifying the

most important treatment concerns. A = Airway. This category includes everything that affects a patent airway, including

a foreign object, fluid from an upper respiratory infection, and edema from trauma or an allergic reaction.

B = Breathing. This category includes everything that affects the breathing pattern, including hyperventilation or hypoventilation and abnormal breathing patterns, such as Korsakoff’s, Biot’s, or Cheyne-Stokes respiration.

C = Circulation. This category includes everything that affects the circulation, including fluid and electrolyte disturbances and disease processes that affect cardiac output.

D = Disease processes. If the patient has no problem with the airway, breathing, or circulation, then the nurse should evaluate the disease processes, giving priority to the disease process that poses the greatest immediate risk. For example, if a patient has terminal cancer and hypoglycemia, hypoglycemia is a more immediate concern.

E = Everything else. This category includes such issues as writing an incident report and completing the patient chart. When evaluating needs, this category is never the highest priority.

When answering a question on an NCLEX examination, the basic rule is “assess before action.” The student should evaluate each possible answer carefully. Usually, several answers reflect the implementation phase of nursing and one or two reflect the assessment phase. In this case, the best choice is an assessment response unless a specific course of action is clearly indicated.

Rule utilitarianism is known as the “greatest good for the greatest number of people” theory.

Egalitarian theory emphasizes that equal access to goods and services must be provided to the less fortunate by an affluent society.

Active euthanasia is actively helping a person to die. Brain death is irreversible cessation of all brain function. Passive euthanasia is stopping the therapy that’s sustaining life. A third-party payer is an insurance company. Utilization review is performed to determine whether the care provided to a patient

was appropriate and cost-effective. A value cohort is a group of people who experienced an out-of-the-ordinary event

that shaped their values. Voluntary euthanasia is actively helping a patient to die at the patient’s request. Bananas, citrus fruits, and potatoes are good sources of potassium. Good sources of magnesium include fish, nuts, and grains. Beef, oysters, shrimp, scallops, spinach, beets, and greens are good sources of iron. Intrathecal injection is administering a drug through the spine. When a patient asks a question or makes a statement that’s emotionally charged,

the nurse should respond to the emotion behind the statement or question rather than to what’s being said or asked.

The steps of the trajectory-nursing model are as follows: –        Step 1: Identifying the trajectory phase –        Step 2: Identifying the problems and establishing goals –        Step 3: Establishing a plan to meet the goals –        Step 4: Identifying factors that facilitate or hinder attainment of the goals –        Step 5: Implementing interventions –        Step 6: Evaluating the effectiveness of the interventions

A Hindu patient is likely to request a vegetarian diet. Pain threshold, or pain sensation, is the initial point at which a patient feels pain. The difference between acute pain and chronic pain is its duration. Referred pain is pain that’s felt at a site other than its origin. Alleviating pain by performing a back massage is consistent with the gate control

theory. Romberg’s test is a test for balance or gait. Pain seems more intense at night because the patient isn’t distracted by daily

activities. Older patients commonly don’t report pain because of fear of treatment, lifestyle

changes, or dependency. No pork or pork products are allowed in a Muslim diet. Two goals of Healthy People 2010 are:

–        Help individuals of all ages to increase the quality of life and the number of years of optimal health

–        Eliminate health disparities among different segments of the population. A community nurse is serving as a patient’s advocate if she tells a malnourished

patient to go to a meal program at a local park. If a patient isn’t following his treatment plan, the nurse should first ask why. Falls are the leading cause of injury in elderly people. Primary prevention is true prevention. Examples are immunizations, weight control,

and smoking cessation. Secondary prevention is early detection. Examples include purified protein derivative

(PPD), breast self-examination, testicular self-examination, and chest X-ray. Tertiary prevention is treatment to prevent long-term complications. A patient indicates that he’s coming to terms with having a chronic disease when he

says, “I’m never going to get any better.” On noticing religious artifacts and literature on a patient’s night stand, a culturally

aware nurse would ask the patient the meaning of the items. A Mexican patient may request the intervention of a curandero, or faith healer, who

involves the family in healing the patient. In an infant, the normal hemoglobin value is 12 g/dl. The nitrogen balance estimates the difference between the intake and use of protein. Most of the absorption of water occurs in the large intestine. Most nutrients are absorbed in the small intestine. When assessing a patient’s eating habits, the nurse should ask, “What have you

eaten in the last 24 hours?” A vegan diet should include an abundant supply of fiber. A hypotonic enema softens the feces, distends the colon, and stimulates peristalsis. First-morning urine provides the best sample to measure glucose, ketone, pH, and

specific gravity values. To induce sleep, the first step is to minimize environmental stimuli. Before moving a patient, the nurse should assess the patient’s physical abilities and

ability to understand instructions as well as the amount of strength required to move the patient.

To lose 1 lb (0.5 kg) in 1 week, the patient must decrease his weekly intake by 3,500 calories (approximately 500 calories daily). To lose 2 lb (1 kg) in 1 week, the patient must decrease his weekly caloric intake by 7,000 calories (approximately 1,000 calories daily).

To avoid shearing force injury, a patient who is completely immobile is lifted on a sheet.

To insert a catheter from the nose through the trachea for suction, the nurse should ask the patient to swallow.

Vitamin C is needed for collagen production. Only the patient can describe his pain accurately. Cutaneous stimulation creates the release of endorphins that block the transmission

of pain stimuli. Patient-controlled analgesia is a safe method to relieve acute pain caused by surgical

incision, traumatic injury, labor and delivery, or cancer. An Asian American or European American typically places distance between himself

and others when communicating. The patient who believes in a scientific, or biomedical, approach to health is likely to

expect a drug, treatment, or surgery to cure illness. Chronic illnesses occur in very young as well as middle-aged and very old people.

The trajectory framework for chronic illness states that preferences about daily life activities affect treatment decisions.

Exacerbations of chronic disease usually cause the patient to seek treatment and may lead to hospitalization.

School health programs provide cost-effective health care for low-income families and those who have no health insurance.

Collegiality is the promotion of collaboration, development, and interdependence among members of a profession.

A change agent is an individual who recognizes a need for change or is selected to make a change within an established entity, such as a hospital.

The patients’ bill of rights was introduced by the American Hospital Association. Abandonment is premature termination of treatment without the patient’s permission

and without appropriate relief of symptoms. Values clarification is a process that individuals use to prioritize their personal values. Distributive justice is a principle that promotes equal treatment for all. Milk and milk products, poultry, grains, and fish are good sources of phosphate. The best way to prevent falls at night in an oriented, but restless, elderly patient is to

raise the side rails. By the end of the orientation phase, the patient should begin to trust the nurse. Falls in the elderly are likely to be caused by poor vision. Barriers to communication include language deficits, sensory deficits, cognitive

impairments, structural deficits, and paralysis. The three elements that are necessary for a fire are heat, oxygen, and combustible

material. Sebaceous glands lubricate the skin. To check for petechiae in a dark-skinned patient, the nurse should assess the oral

mucosa. To put on a sterile glove, the nurse should pick up the first glove at the folded border

and adjust the fingers when both gloves are on. To increase patient comfort, the nurse should let the alcohol dry before giving an

intramuscular injection. Treatment for a stage 1 ulcer on the heels includes heel protectors. Seventh-Day Adventists are usually vegetarians. Endorphins are morphinelike substances that produce a feeling of well-being. Pain tolerance is the maximum amount and duration of pain that an individual is

willing to endure.

Lupus is an autoimmune disease characterized by acute and chronic inflammation of various tissues of the body. Autoimmune diseases are illnesses that occur when the body's tissues are attacked by its own immune system