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Nclex Must knows!

Nclex

QuestionAnswer
4 c's of communication clear,concise,complete,complete
5 rights of delegation right tasks , right circumstances,right person, right direction, right supervision and evaluation
5 rights of drug administration right patient, right drug,right dose, right route,and right time
The rule of nine for infants The head and neck are 21% of the Bsa Each arm and hand is 10% of BSA Each leg and foot is 13.5% of Bsa Chest and stomach are 13% of BSA Back is 13% of BSA Buttocks are 5% of BSA Groins are 1% of BSA
Bleeding Precautions Razor(electric),NO aspirin,needles (small gauge), decrease needle sticks, protect from injury,
Bleeding Precautions watch for observe for hematuria, melena, nosebleeds, gingival bleeding, bruising
Bleeding Precautions implement when using anticoagulants, liver disease present,
Glucose mg/dL 70-110 low <50 high >400
Potassium mEq/L 3.5- 5.0 low <2.5 high >6.5
Hemoglobin Men 14-18g/dL and women 12-16g/dL low <5 high > 20
Hematocrit men: 40-54% women 38-47% low <15 high >60
Wbc 5,000 - 10,000 low 2,500 immunosupressed high 30,000 infection
Sodium 135-145 mEq/L low < 120 hyponatremia high > 160 hypernatremia
Platelets 150,000-400,000 low < 50,000 high > 1 million
BUN 10-20mg/dL high > 120
ABG ph 7.35-7.45 low <7.25 high >7.55 Pa02 80-100 mmHg PaC02 35-45 mmHg C02 low<20 high >60 HC03 22-26 mEq/L low<15 high >40 Sa02 94-100% 75% or less
PT 11.0-12.5 >20
INR 1.3-2.0
PTT 20-36 >68
Creatinine men 0.6-1.3 mg/dL Women 0.5-1.0 mg/dL >4
RBC men 4.7-6.1 million/mm3 women 4.2-5.4 million/mm3
Digoxin 0.5-2ng/mL >2.0
bleeding time 1-9 minutes >15 minutes
Hemoglobin A1C Good control 2.5-5.9% Fair control 6-8% Poor control >8%
MAGNesium 1.3-2.1 low <0.5 high >3
Total cholesterol 122-200 mg/dL
Total cholesterol good cholesterol HDL men mean 45-50 mg/dL Women mean 55-60 mg/dL Higher than 35 is good
Total cholesterol Bad cholesterol LDL 60-180 mg/dL want low bc high is bad
Urinalysis alb 0-8mg/dL pH 4.6-8.0 WBC 0-4 glucose is negative( no glucose in urine)
albumin 3.5-5.0 g/dL
lithium level .6-1.2 mEq/L therapeutic high > 1.5
bilirubin total 0.3-1.0 mg/dL high >12 Indirect 0.2-0.8 Direct 0.1-0.3
ammonia 10-80mg/dL
ALT=SGPT 4-36 U/L
ALT=SGOT 0-35 U/L
Total Protein 6.4-8.3 g/dL
ESR men 0-10 mm/hr women 0-20 mm/hr
Phosphorus Phosphate 3.0-4.5 low L1
Diabetes Mellitus Type 1 iddm polyuria,polydipsia,polyphagia,weight loss, fatigue,fx infections,rapid onset,insulin dependent,early onset before 15 yrs old, 0 insulin produced,autoimmune disorder. Ketoacidosis. Insulin dependent
Diabetes Mellitus Type 2 niddm polyphagia,polydipsia,polyuria,fatigue,uti,weight increase,eye problems,slow onset,insufficient insulin productio, ketoacidosis not common,adults after 40 most often, may need insulin.
blood sugar high hot and dry= sugar high
blood sugar low cold and clammy=need some candy =sugar low
hypoglycemia T.I.R.E.D. T Tachycardia I Irritability R restless E excesive hunger D diaphoresis,depression
Diabetes insipidus (has nothing to do with sugar)
Lispro (Humalog) Onset 15 Minutes, Peak 1 Hour,Duration of Action 4 Hours
Regular Onset 30-60 Minutes,Peak 2-4 Hour,Duration of action 5-7 Hours
NPH (Lente) Onset 2 Hours,Peak 6-12 Hours,Duration of action 18-28 Hours
Ultralente Onset 4-6 Hours,Peak 12-16 Hours, Duration of action 36+ Hours
70/30 Mix Onset 60 Minutes,Peak 2-12 Hours,Duration of action 18-28 Hours
50/50 Mix Onset 30 Minutes,Peak 2-6 Hours,Duration of action 12-14 Hours
ADPIE (A Delicious PIE): The steps in the nursing process are: Assessment, Diagnosis, Planning, Intervention and Evaluation.
PASS (Pull, Aim, Squeeze and Sweep): When handling a fire extinguisher, you first pull the pin out. You next aim the nozzle towards the base of the fire. Next you squeeze the handle, and sweep in a back and forth pattern to extinguish the fire.
RACE Rescue,Alarm, Contain, and Extinguish): Used for putting out fires. Rescue any people to an area of safety. Call 911 to activate the alarm. Contain the fire by shutting doors and turning off oxygen. Extinguish the fire using the proper extinguisher
CAUTION UP: The early warning signs of Cancer. Change in bowel & bladder habits,lesion that doesnt heal,Unusual bleeding or discharge,lump, Indigestion or difficulty swallowing,changes in a mole or wart, coughing or hoarseness, weight loss and Pernicious anemia.
SSS (Sugar, Salt and Sex): The adrenal gland hormones. Sugar (Glucocorticoids), Salt (Mineral Corticoids) and Sex (Androgens).
MACHINE: Causes of Hyperkalemia: Medications (NSAIDs, ACE Inhibitors), Acidosis, Cellular destruction (traumatic injury, burns), Hemolysis, Intake (excessive), Nephrons (renal failure) and Excretion (impaired).
MURDER: Signs and Symptoms of Hyperkalemia: Muscle weakness, Urine (oliguria, anuria), Respiratory distress, Decreased cardiac contractility, ECG changes and Reflexes (hyperreflexia, areflexia).
CATS: Symptoms of Hypocalcemia: Convulsions, Arrhythmias, Tetany and Spasms or Stridor.
The order of the prevelance of White Blood Cells: Never (Neutrophils, 60%) Let (Leukocytes, 30%) Monkeys (Monocytes, 6%) Eat (Eosinophils, 3%) Bananas (Basophils 1%).
HEART: Causes of Atrial Fibrillation: congestive Heart failure, Enlarged atria, Alcohol, Rheumatic heart disease and hyperthyroidism.
SITTT: Causes of hematuria: Stone, Infection, Trauma, Tumor and Tuberculosis.
All Dogs Eat Kibble: Fat-soluble vitamins: Vitamins A, D, E and K.
ABCD Rule for determining if a mole is malignant: Asymmetry, Border, Color and Diameter.
For placement of EKG leads: white on the right, with smoke (black) over fire (red).
The 5 S's of steroid side effects: Sick, Sad, Sex, Salt and Sugar (increases blood sugar).
PHAROH: Signs and Symptoms of Nephritic Syndrome: Proteinuria, Haematuria, Azotaemia, RBC casts, Oliguria and Hypertension.
SADAFACES: Criteria for Depression by DSM IV : Sleep disturbance, Appetite/weight change, Dysthymia, Anhedonia, Fatigue, Agitation, Concentration, Excessive guilt and Suicidal ideation/plans/attempts.
For Diabetes: Hot and dry is a sugar high (Hyperglycemia). Cool and clammy needs some candy (Hypoglycemia).
PERRLA: Pupils Equal Round Reactive to Light and Accommodation.
SALT LOSS: Signs and Symptoms of Hyponatremia: Stupor/coma, Anorexia, Lethargy, Tendon reflexes decreased, Limp muscles, Orthostatic hypertension, Seizures/headache and Stomach cramping.
The 5 P's of Compartment Syndrome: Pain, Pressure, Pulselessness, Parathesia and Paralysis.
MONA: Immediate treatment of a myocardial infarction: Morphine sulfate, Oxygen, Nitroglycerine and Aspirin.
UNLOAD FAST: Treatment of congestive heart failure: Upright sitting, Nitroglycerin, Lasix, Oxygen, Aminophylline, Digoxin, Fluids (decrease), Afterload (decrease), Sodium (decrease) and Tests (Digoxin level, Arterial Blood Gas, Potassium).
COAL: For cane use: Cane Opposite Affected Leg.
SPASM: Heart Murmur: Stenosis, Partial obstruction, Aneurysms, Septal defects and Mitral regurgitation.
What is fluid volume excess? Retaining too much water and sodium in the vascular space.
term for fluid volume excess Hypervolemia
can congestive heart failure throw you into fve? 3. Decrease in cardiac output, decrease in kidney perfusion, decrease in urine, too much fluid in the vascular space
How can renal failure throw you into fluid volume excess? 4. If your kidneys are not working then the fluid will be retained in the vascular space
How can IV fluids with sodium induce hypervolemia? Because sodium makes you retain water
Alka-Seltzer contains a lot of what? Sodium
How can Alka-Seltzer throw you into hypervolemia? 7. Alka Seltzer has a lot of sodium… so if you are taking alka seltzer the sodium will make you retain fluid in the vascular space
Fleets enemas contain a lot of what? Sodium
How can a fleets enema throw you into hypervolemia? Increase in sodium intake, therefore you retain fluid in vascular space
What is the normal action of aldosterone? Aldosterone makes you retain sodium and water in the vascular space
How can aldosterone throw you into hypervolemia? If you have too much aldosterone then you are retaining too much sodium and water
What is the name of the disease a patient can have that will induce hypervolemia due to too much aldosterone? Primary hyperaldosteronism or Cushings
What is the normal action of ADH, and what does ADH stand for? -Diuretic hormone. Makes you retain water in vascular space
How can ADH throw you into hypervolemia? If you have too much ADH, you retain too much water in the vascular space (SIADH
Where is ADH stored? Pituitary
What will the effects be on the body if a patient is producing too much ADH and what is the name of this disease? If you have too much ADH you will retain too much WATER….SIADH
What will the effects be on the body if the patient does not have enough ADH and what is the name of this disease? Diabetes Insipidus—diurese—shock (losing water)
What happens to your veins when you are hypervolemic? They distend. (Full)
Why does the hypervolemic patient develop edema? The vascular space gets full and gets to where it can’t hold anymore and the fluid eventually leaks into the tissues
Why does the hypervolemic patient develop ascites? 20. Vascular space gets so full it can’t hold any more so the fluid leaks into the abdomen. Therefore the vascular volume goes down.
What is ascites Fluid in the abdomen (peritoneum), third spacing
When you have a patient who is developing ascites, you know you are supposed to measure the abdominal girth every day. If the abdominal girth increases every day, what does that tell you about the vascular space? There is still too much fluid in the vascular space and the excess is pouring over into the abdomen
Define CVP. Where is CVP measured? Central Venous Pressure. Right atrium of the heart
Created by: tko27girl