NCLEX-PN Review: Essential Nursing Concepts and Procedures, Exams of Nursing

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NCLEX-PN Review

Do not delegate what you can EAT - ANS Don't delegate what you can: E- Evaluate A- Assess T- Teach As a PN go to the RN and the RN will contact the HCP Follow up with performed task that has been delegated. Addisons: Down, Down, Down, Up, Down Cushings: Up, Up, Up, Down, Up - ANS Addisons: Hyponatremia, Hypotension, Decreased blood volume, Hyperkalemia, Hypoglycemia Cushings: Hypernatremia, Hypertension, Increased Blood Volume, Hypokalemia, Hyperglycemia No Pee, No K - ANS Don't give potassium without adequate urine output. (Adult: 30 ml/hr Child: 20- ml/hr) Monitor I&O EleVate Veins & DA*ngle Arteries for - ANS Better perfusion so as not to have impaired tissue perfusion Arteries Veins - ANS Away from the heart To the heart HPV - ANS virus has ben linked to cervical cancer

1 gram - ANS 1 ml Cholesterol Levels - ANS LDL: lower than 130mg/dL HDL: 30-70 mg/dL Total <200 mg 1 pound - ANS 453.6 grams 1 liter of fluid/1 kg - ANS 2.2 lbs Any procedure ending in -scopy - ANS Monitor for gag reflex post op. DONT offer any PO food or liquids until gag reflex return. APGAR Score - ANS A= appearance (color all pink, pink and blue, blue P= pulse (>100, <100, absent) G= grimace (cough, grimace, no response) A= activity (flexed, flaccid, limp) R= respirations (strong cry, weak cry, absent) Taken 1 min after birth and 5 min after birth Airborne Precautions My Chicken Hez TB

or MTV - ANS Measles Chicken Pox/Varicella Herpes Zoster/Shingles TB or Measles TB Varicella-Chicken Pox/Herpes Zoster-Shingles Private room-negative pressure with 6-12 air exchanges/hr N95 mask for TB Air Embolism - ANS turn pt on left side with HOB flat or tendelenburg Provide O Monitor VS Droplet Precautions *Think, Spiderman! S S

S P P P I D E R M M M

An - ANS Sepsis Scarlet fever Streptococcal pharyngitis Parvovirus B Pneumonia Pertussis Influenza Diphtheria (pharyngeal) Epiglottis Rubella Mumps Meningitis Mycoplasma or meningeal pneumonia Adenovirus

Private room or cohort & Mask Contact Precautions *Mrs. Wee! M R S W E E - ANS Multidrug resistant organism Respiratory infection Skin infections Wound infections Enteric infections-C. difficile Eye infection-Conjuctivitis Contact Precautions Skin Infections *VCHIPS V C H I

P

S - ANS V-varicella zoster C-cutaneous diphtheria H-herpes simplex I-impetigo P-pediculosis S-scabies Cranial Nerves (12) - ANS Oh, Oh, Oh To Touch And Feel A Girl's Vagina, Ahhhh, Heaven

1. Olfactory
2. Optic
3. Oculomotor
4. Trochlear
5. Trigeminal
6. Abducens
7. Facial
8. Vetibulocochlear
9. Glossopharyngeal
10. Vagus
11. Accessory
12. Hypoglossal Triglyceride level - ANS 30- Erikson stages - ANS Trust v Mistrust (Age: INFANCY 0-1 1/2 years)

Autonomy v shame (Age: Early Childhood 1 1/2-3 years) Initiate v guilt (Age: Preschool 3-6 years) Industry v inferiority (Age: School Age 6-12 years) Identity v Role confusion (Age: Adolescence 12-19 years) Intimacy v Isolation (Ages: Early Adulthood 20-25 years) Generativity v stagnation (Ages: Middle Adulthood 26-64 years) Integrity v Despair (Age: Maturity/Death 65-death) Pain assessment - ANS P.O medication reassess pt in 60 min IV pt reassess in 30 min PQRSTU Provocative/palliative factors ; Quality of the pain; Region or Radiation of the pain(location); Severity of the pain (scale/facial grimace); Timing of the pain (continuous or intermittent); and how the pain affects yoU S/S of Air/Pulmonary Embolism - ANS Chest pain Difficulty breathing Tachycardia Pale/Cyanotic Sense of impending doom NSG INTV: *Turn pt to left side (trendelenburg) and lower the HOB, Provide O2, notify HCP Woman in labor with un-reassuring FHR - ANS Late decels Decreased variability Fetal bradycardia, etc...

NSG INTV:

*Turn on left side and give O2, stop Pitocin, Increase IV fluids Postpartum Assessment - ANS Breast Uterus Bowel function Bladder function Lochia Episiotomy/C- sect incision Peak and trough - ANS Peak is taken 1 hr after a dose is administered Trough is taken 30 min before the next dose Tube feeding with decreased LOC (unconscious) - ANS Position on right side (promotes emptying of the stomach) with HOB elevated (to prevent aspiration) During Epidural puncture pt is in what position? - ANS Side-lying or upright hunch over Pt with Heat Stroke - ANS Lie flat with legs elevated due to the drop in BP and once flat the BP will increase. During Continuous Bladder Irrigation (CBI) - ANS Catheter is taped to thigh so leg should be kept straight. No other positioning restrictions. Catheter size 14-16 fr. After an Myringotomy-(surgical incision into the eardrum, to relieve pressure or drain fluid) - ANS Position on side of affected ear after surgery (allows drainage of secretions)

Avoid getting wet M.D removes the first packing After Cataract Surgery - ANS Pt will sleep on unaffected side with a night shield for 1-4 weeks DON'T COUGH, strain, bend over, or rub eye Elevate HOB (fowlers) SAFETY: SR up x2, bed low and locked, CB within reach. After Thyridectomy (removal of the thyroid gland) - ANS NSG INTV: Low or Semi-Fowler's, support head, neck, and shoulders Avoid taking med with iodine Have tracheotomy tube at bedside. Infant with Spina Bifida - ANS Position prone so that sac does not rupture Tuen to one side when feeding Monitor for s/s of ICP or infection Note any physical movement Prone to a latex allergy Buck's Traction (skin traction) - ANS Elevate foot of bed for counter-traction Inspect the skin every 8 hrs. PREOP *RISK FOR INFECTION After Total Hip Replacement - ANS Don't sleep on operated side, don't flex hip more than 90 degrees. Avoid crossing legs

Monitor pain levels Abduction not adduction Internal rotation not external *RISK FOR INFECTION Prolapsed Cord (umbilical cord) - ANS Apply a saline soaked gauze back. Push upwards with gloved hand Knee chest position or Trendelenburg or hips elevated Infant with Cleft lip - ANS Position on back or in infant seat to prevent trauma to suture line. While feeding, hold in upright position Usually performed 18 months to 2 years. To prevent Dumping Syndrome (post-operative ulcer/stomach surgeries) - ANS Eat in reclining position, lie down after meals for 20-30 minutes (also restrict fluids during meals, low CHO & fiber diet, small frequent meals) Usually after a new peg tube feeding BRAT diet for Gastritis - ANS Bananas Rice Applesauce Toast Visual Changes - ANS Retina Detachment- curtain over eyes vision (black spots may indicate a bleed) Macular Degeneration- loss of central vision (like a dot in the middle) Cataracts- blurry vision Glaucoma- tunnel vision *acute angle closure glaucoma is a med. emergency

Administration of Enema - ANS Position pt in left side-lying (Sim's) with knees flexed May cause F&E imbalance. Monitor VS After Supratentorial Surgery (incision based hairline) - ANS Elevate HOB 30-45 degrees After Infratentorial Surgery (incision at nape of neck) - ANS Position pt flat and lateral on either side Any adjustment to a benzodiazepine (ex: -zam/pam/lam) - ANS initiate seizure precaution Toxoplasmosis - ANS Caused by: undercooked meat, cat feces, soil Drugs that cause ototoxicity - ANS specific antibiotics (-mycin), loop diuretics (ex: Lasix), nonsteroidal anti-inflammatory agents (Aspirin) , and specific chemotherapy agents. During Internal Radiation pt should be on - ANS Bedrest while implant on place Private room Autonomic Dysreflexia/Hyperreflexia S/S include what? And what position should you place pt? - ANS Pounding headache, profuse sweating, nasal congestion, goose flesh, bradycardia, hypertension. Place client in Sitting position (elevate HOB) first before any other implementation. SHOCK patient caused by Hemmorage - ANS s/s: Bleeding and Drainage s/s: low BP, increase P, and pale/diaphoretic skin

INTV;

Bedrest with extremities elevated 20 degrees Knees straight Head slightly elevated (modified Trendelenburg) Strabismus - ANS cover good eye to strengthen weak eye muscle. Surgery correction before 3 years old. FIRE (and fire extinguisher) procedure - ANS Rescue pt Activate emergency response Confine the fire Extinguish fire Pull Aim Squeeze Sweep When Head Injury takes place elevate - ANS HOB 30 degrees to decrease ICP Monitor for s/s of ICP (#1 decreased LOC and a high shrill cry in an infant) ICP occurs may give mannitol Peritoneal Dialysis when Outflow is inadequate you must - ANS Turn pt from side to side BEFORE checking for kinks in tubing Myasthenia Gravis worsens with _________ and Improves with __________. - ANS Exercise; Rest

In Myasthenia Crisis a Positive reaction to _________ will improve symptoms. - ANS Tensilon (edrophonium) s/s: dysphagia Cholinergic Crisis can be caused by excessive medication so you must - ANS Stop medication Giving Tensilon (edrophonium) will make it worse. Head injury medication includes - ANS Mannitol (osmotic diuretic) it crystallizes at room temperature so ALWAYS use filter needle. Thrombocytopenia - ANS PLT <20, Prior to a liver biopsy it's important to be aware of the lab result for ______________. - ANS Prothrombin time (PT) From the ass (diarrhea) = ____________ From the mouth (vomitus) = ____________ - ANS Metabolic acidosis Metabolic alkalosis Myxedema/hypothyroidism is r/t - ANS Slowed physical and mental function, sensitivity to the cold, and dry skin & hair. Graves' disease/hyperthyroidism is r/t - ANS Accelerated physical and mental function, sensitivity to heat, fine/soft hair, tremors, tachycardia, nervousness, insomnia Bulging eyes Thyroid storm r/t - ANS Increased temperature, pulse, and HTN

tx: PTU and Tapazole Hypo-parathyroid is r/t - ANS CATS: Convulsions Arrhythmias Tetany (decreased calcium) Spasms Stridor High calcium, low phosphorus diet *Monitor Ca levels Hyper-parathhyroid is r/t - ANS Fatigue, muscle weakness, renal calculi, back and joint pain (increased calcium). Low calcium, high phosphorus diet *Monitor Ca levels Hypovolemia is r/t - ANS Increased temp, hypotension, anxiety. increased respirations and increased, weak heart rate, decreased central venous pressure, weight loss, poor skin turgor, dry mucous membranes, sunken eyes, decreased output, increased specific gravity of the urine, dark-colored and odorous urine, an increased hct, and an altered LOC Monitor daily wt, VS, and I&O. Specific Gravity - ANS 1.010-1. Hypervolemia is r/t - ANS Bounding pulse, SOB, dyspnea, rales/crackles, peripheral edema, HTN, lethargy, nauseas, CNS sign, urine specific gravity <1. Place in Semi-Fowlers Common in heart and kidney failure patients.

Diabetes Insipidus (decreased ADH) - ANS s/s: Excessive urine output, thirst, dehydration, & weakness. Administer Pitressin via intranasal. (monitor for runny nose or nasal congestion) Encourage fluid intake Dawm Phenomenon - ANS Occurs before breakfast tx: intermediate-acting insulin SIADH (increased ADH) - ANS s/s: Change in LOC, decreased deep tendon reflexes, tachycardia, N/V/A, HA. tx: Administer Declomycin & diuretics Hypokalemia is r/t - ANS s/s: Muscle weakness and dysrhythmias tx: Increase K (raisins, bananas, apricots, oranges, beans, potatoes, carrots, celery) Cardiac: peak p waves, flat T waves, depressed ST segment, and U waves Hyperkalemia is r/t - ANS MURDER M:uscle weakness U:rine (oliguria/anuria) R:espiratory depression D:created cardiac contractility E:CG changes (heart blocks, asystole, and ventricular fibrillation) R:eflexes Causes: in the early stages of massive cell destruction ex: trauma, burns, sepsis, or metabolic or respiratory acidosis. intestinal obstruction, Addison's disease. Cardiac changes: a wide, flat P wave; a prolonged PR interval; a widened QRS complex; and narrow, peaked T waves. Tx: Kayexalate to reduce potassium levels

AVOID FOOD HIGH IN POTASSIUM

Hyponatremia is r/t - ANS Nausea, muscle cramps, increased ICP, muscular twitching, and convulsions. Osmotic diuretics and fluids. Monitor pt PO fluid intake Hypernatremia is r/t - ANS Increased temperature, weakness, disorientation/delusions (mania) , hypotension, tachycardia. Hypotonic solution. Mania pt: provide foods high in claroies Hypocalcemia is r/t - ANS CATS: C:onvulsions A:rrhythmias T:etany S:pasms & Stridor EX: prolonged bed rest Hypercalcemia is r/t - ANS Muscle weakness, lack of coordination, Abd pain, confusion, absent tendon reflexes, sedative effect on CNS. Hypomagnesia is r/t - ANS Tremors, tetany, seizures, dysrhythmias, depression, confusion, and dysphagia. Digoxin toxicity Hypermagnesia is r/t - ANS CNS depression, hypotension, facial flushing, muscle weakness, absent deep tendon reflexes, shallow respirations.

EMRGENCY

Addison's is r/t Hyponatremia - ANS Hyposecretion of adrenal hormone. Hyponatremia, hyperkalemia, dark pigmentation, decreased resistance to stress, fx, alopecia, wt loss, and GI distress. *increase sodium intake CRISIS: N/V, confusion, ABD pain, extreme weakness, hypoglycemia, dehydration, decreased B/P. Admin a high salt diet tx: Mineralcorticoidsteriod (monitor glucose for s/s of hyperglycemia) Insect/worm in ear (mucous membranes) - ANS Place mineral oil or diluted alcohol solution in ear and place pt on affected ear Use a flashlight to attract insect "Ineffective response" - ANS look for the abnormal or negative Corticosteroids - ANS taken in the morning because it mimics the body natural release of cortisol Avoid aspirin and OTC med. Cause hyperglycemia Magnesium Levels - ANS 1.6-2.6 mg/dL Low mg can lead to Torsades which is ventricular dysrhythmia. Cushings is r/t - ANS Oversecretion of gluccocorticosteroids. Hypernatremia, hypokalemia, hyperglycemia, prone to infection, muscle wasting, weakness, edema, HTN, hirsutism, moonface/buffalo hump. *low sodium intake Tx: steroids

Stages of Grief - ANS 1. Denial

2. Anger
3. Barganing
4. Depression
5. Acceptance Pheochromocytoma is r/t - ANS Hypersecretion of epi., persistent HTN, increased HR, hyperglycemia, diaphoresis, tremor, pounding HA. Pt must avoid stress. Take frequent baths and rest breaks, and avoid cold and stimulating foods, and must have surgery to remove tumor. Tx: glucocorticoid Neuroleptic malignant syndrome (NMS) is like S&M - ANS s/s: Hot (hyperpyrexia) Stiff (increased muscle tone) Sweaty (diaphoresis) B/P, pulse, and respirations go up and they start to Drool Never get pregnant with a German (rubella). Why? - ANS When pt is pregnant German measles (rubella) is dangerous while regular measles (rubeola) is not. Avoid getting pregnant for 3 months. Tetralogy of fallot; remember HOPS, POSH or think DROP (child drops to floor or squats) - ANS D:efect, septal R:ight ventricular hypertrophy O:verriding aorts P:ulmonary stenosis RX: digoxin

MAOI's are used as antidepressants, so you might think of how pirates might say "arrr" when depressed. So the 3 meds with an arr sound in the middle are: - ANS -Parnate -Marplan -Nardil Autonomic dysreflexia is a potentially life threatening emergency so you must do 4 main things: - ANS - Elevate HOB to 90 degrees -Loosen constrictive clothing -Assess for bladder distention and bowel impaction -Administer antihypertensive meds (may cause stroke MI, seizure) To remember the MAOIs think of PANAMA. - ANS PA-parnate NA-nardil MA-marplan -metallic bitter taste For Digoxin you must: - ANS -Check pulse, it is < 60 in adults, < 100 in children, <70 for older child, you must hold *Apical Pulse -Check dig levels and K+ levels Normal level: 0.5- Amphojel is for the: - ANS -Tx of GERD and kidney stones NSG INTV: Increase fluids 1500-3000 ml -Look for constipation Vistaril is for the: - ANS -Tx of anxiety and also itching

-Watch for dry mouth -Given preop commonly Versed is given for: - ANS -Conscious sedation -Look for respiration depression and hypotension Sinemet is for: - ANS -Tx of Parkinson's side effect: -Sweat, Saliva, & Urine may turn reddish brown occasionally~causes drowsiness Artane is for: - ANS -Tx of Parkinson's -Has a sedative effect Cogentin is for: - ANS -Tx of Parkinson's and extrapyramdial effects of other drugs Tigan is for tx of: - ANS Postop N/V and for nausea associated with gastroenteritis Timolol (Timoptic) trats - ANS Glaucoma *contradicted for asthma pt due to side effects of bronchospasm Kawasaki's leads to? - ANS Cardiac problems. Also anurysms Calcium and Phosphorus work hand in hand - ANS If you have hypercalemia then you have hypophosphemia and vice versa. Dilantin (phenytoin) therapeutic range: - ANS 10-20 mcg/mL Monitor for gum hypertrophy

Phosphorus level - ANS 3-4.5 mg Hbg A1C - ANS <7% for DM pt 4-6% for non-DM pt HYPOTONIC SOLUTION COMPLICATION - ANS Monitor pt closely because of the risk for complication it causes fluid to pull away from the body and into interstitial tissue. ex: tap water Theophylline therapeutic range: - ANS 10-20 Action: is given to relax bronchial smooth muscle an broncodilator s/s of toxicity: stomache tachycardia sweating profusely Acetaminophen therapeutic range: - ANS 10-20 Can cause liver damage Monitor liver function Therapeutic Diets - ANS Renal- High calorie, carb. Low protein, potassium, and sodium. Fluid restriction. Monitor I&O. Gout- Low purine (like can foods) Heart Healthy Diet- Low fat Lithium therapeutic range: - ANS 0.5 - 1.5 Toxicity can occur if the patient becomes dehydrated. Risk for hyponatremia

Pt must be hydrated Down Syndrome - ANS defect in chromosome 21. s/s: protruding tounge, cardiac problems, crease in palm Osteomyelitis is an infectious bone disease, so you must give? - ANS Blood cultures and antibiotics, then if necessary surgery to drain abscess. The two signs symptoms of nephrotic syndrome are edema and hypotension. So you must? - ANS Turn and reposition (risk for impaired skin integrity). TQ2H s/s: proteinuria, hypoalbuminemia, and edema Monitor Vs, I&O, and daily wt Low sodium diet and fluid restriction Tx: corticosterois Herniated disk - ANS s/s: lower back pain, Weakness whenraising the big toe and ankle, Numbness and pain in the foot, and Pain radiating down the posterior hip and thigh Procedures you DON'T COUGH, sneeze, strain - ANS Glacoma or eye surgery Brain surgery Hernia Tonsillectomy Myringectomy Hypophysectomy Enema precautions - ANS Prevent the overuse of enema due to throwing off the electrolyte balance of the body. Position the pt in left sims.

Diarrhea and Vomiting precautions - ANS Diarrhea: give pt Gatorade due to the throw off the the electrolyte in the body Vomiting: give patient ginger ale (stir the bubbles) or ginger base products. Monitor for fluid and electrolyte imbalance. Monitor skin tugor, mucous membranes, eye area, skin color Vitamin K *shot for babies - ANS given to babies after birth to help with the clotting factor. (prevent hemmorage) Due to the babies lack of intestinal flora (bacteria) Clotting time Bleeding time - ANS 8-15 minutes 1-6 minutes Calcium - ANS 8.6-10.6 Sodium - ANS 135-145 C&S test - ANS Always do the culture before the administration of the antibiotic How to treat a patient with dermatitis? - ANS An oatmeal bath Mixing Insulin - ANS When mixing insulin it's Clear before Cloudy ex: Regular insulin before Insulin NPH Insulin administration - ANS injection areas: abdomen, thigh, and hips

Rotate injection sites and 1.5 inches apart Don't rub site 45-90 degree angle and leave for 5 sec Post-op Patient positioning - ANS Conscious: Semi or High Fowler's, Bed low, Side rails up x2, and call bell in reach. Unconscious: Side *due to risk of aspiration, Bed low, side rails up x2. How to test for H. Pylori? - ANS a breath test due to the release of bacteria and organism through breaths. Birth Contraceptives (not given to pt) - ANS Hx of DVT or spontaneous bleeding Hepatitis COPD Cholecystitis Antibiotics decrease the effectiveness of contraceptives MI - ANS Take VS and assess pain level tx: M.O.N.A Morphine O2 Nitro Aspirin Lab Values: Troponin, WBC, CK-MB, CBC, ESR Nitroglycerin - ANS Sublingual q5 min up to 3 times. If chest pain isnt relieves after 3rd time contact 911 or M.D.

Check BP after each admin of nitro. Symptoms - ANS Symptoms can only be described by the person feeling them. Subjective data Sign - ANS Signs are just what they sound like: indicators of a problem. (Usually visible) Objective data Anything in the airway area - ANS Monitor O2 sat, Resp, lung sounds Early s/s: restlessness, tachycardia, and inspiratory stidor. Late: Cyanosis and decreased LOC Chronic: clubbing Allergy to Pencillin - ANS Avoid drugs with -cillin and cef-, ceph- Anything ending with -ase (enzymes) - ANS Pertaining to the pancreas. Meds are usually given through juice or apple sauce and meals. Perform oral care around mouth after because the enzymes can breakdown skin. Bilirubin (range: 0.2-1.0) - ANS Pertaining to the liver Ascites pt - ANS Monitor wt and abd assessment (measurement). Admin diuretic. Continue to monitor wt and abd. (reassess for effectiveness of diuretic) Usually in liver problem patients Lactulose - ANS given to pt with hepatic encephalopathy (avoid steak) to help eliminate ammonia in the colon and bacterial growth. (given for elevated ammonia levels. NORMAL: 10-80 mcg ) Hydrocephalus pt with ventriculoperitoneal shunt - ANS Done after 6 months. post op: position infant flat