Exam (elaborations)
HESI Hints and NCLEX Gems Answering NCLEX questions
HESI Hints and NCLEX Gems Answering NCLEX questions
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1HESI Hints and NCLEX Gems
Answering NCLEX questions
o Maslow’s Hierarchy of Needs
Physiologic
Safety
Love and Belonging
Esteem
Self-Actualization
o Nursing Process
Assessment
Diagnosis
Planning
Implementation
Evaluation
o ABCs
Airway
Breathing
Circulation
Normal Values
o Hgb
Males 14 – 18
Females 12 – 16
o Hct
Males 42 – 52
Females 37 – 47
o RBCs
Males: 4.7 – 6.1million
Females: 4.2 – 5.4 million
o WBCs
4.5 – 11K
o Platelets
150 – 400K
o PT (Coumadin/Warfarin)
11 – 12.5 sec
INR and PT TR = 1.5-2 times normal)
o aPTT (Heparin)
60 – 70 sec
o BUN: 10 – 20
o Creatinine: 0.5 – 1.2
o Glucose: 70 – 110
o Cholesterol: <200
o Bilirubin newborn: 1 – 12
o Phenylalanine
Newborn: <2
Adult: <6
o Na: 135 – 145
o K: 3.5 – 5.0
Hypokalemia: Prominent U waves, Depresses ST segment, Flat T waves
Hyperkalemia: Tented T waves, prolonged PR interval, wide QRS
, 2
o Calcium: 9 – 10.5
Hypocalcemia: muscle spasms, convulsions, cramping, tetany, pos Trousseau’s, pos Chvostek’s,
prolonged ST interval, prolonged QT segments
o Mg: 1.5 – 2.5
o Cl: 96 – 106
o Phos: 3 – 4.5
o Albumin: 3.5 – 5
o Specific Gravity: 1.005 – 1.030
o HgbA1C:
Ideal = 4-6%
Ok (120 days) <7%
o Dilantin TR: 10 – 20
o Lithium TR: 0.5 – 1.5
o Arterial Blood Gas
pH = 7.35 – 7.45
CO2 = 35 – 45
HCO3 = 22 – 28
O2 = 80 – 100
O2 Sat = 95 – 100%
Antidotes
o Digoxin – Digiband
o Coumadin – Vit K
o Benzos – Flumzaemil (Tomazicon)
o Heparin – Protamine Sulfate (Keep aPTT and PTT at 1.5-2 times normal)
o Tylenol – Mucomyst (loading dose + 17 doses)
o Opiates (narcotics analgesics, heroin, morphine) – Narcan (naloxone)
o Cholinergic meds (myesthenic bradycardia) – Atropine
o Methotrexate – Leucovorin
Delegation
o RN only
Blood products (2 RNs must check)
Clotting factors
Sterile dressing changes and procedures
Assessments that require clinical judgment
Ultimately responsible for all delegated duties
o Unlicensed Assistive Personnel
Non-sterile procedures
Precautions and Room Assignments
o Universal (Standard) Precautions – HIV initiated
Wash hands
Wear gloves
Gowns for splashes
Masks and Eye protection for splashes and droplets
Don’t recap needles
Mouthpiece of Ambu-bag for resuscitation
Refrain from giving care if you have skin lesions
o Droplet (Respiratory) Precautions – wear mask
Sepsis, scarlet fever, strep, fifth disease (Parvo B19), pertusis, pneumonia, influenza, diphtheria,
epiglottitis, rubella, rubeola, meningitis, mycoplasma, adenovirus, rhinovirus
, 3
RSV (needs contact precautions too)
TB (Respiratory isolation)
o Contact Precautions = universal + goggles, mask, and gown
o No infectious patients with immunosuppressed patients
Clean with clean
Dirty with dirty
Misc.
o Rifampin (for TB) – rust/orange/red urine and body fluids
o Pyridium (for bladder infection) … Orange/red/pink urine
o Glasgow Coma Scale … < 8 = coma
o Myasthenia Gravis
Myasthenic Crisis = Weakness with change in vitals (give more meds)
Cholinergic Crisis = Weakness with no change in vitals (reduce meds)
o Diabetic Coma vs. Insulin Shock … Give glucose first – If no help, give insulin
o Fruity Breath = Diabetic Ketoacidosis
o Acid-Base Balance
If it comes out of your ass, it’s Acidosis.
Vomiting = Alkalosis
o Skin Tastes Salty = Cystic Fibrosis
o Lipitor (statins) in PMs only – No grapefruit juice
o Stroke
Tongue points toward side of lesion (paralysis)
Uvula deviates away from the side of lesion (paralysis)
o Hold Digoxin if HR < 60
o Stay in bed for 3 hours after first ACE Inhibitor dose
o Avoid Grapefruit juice with CCBs
o Anthrax = Multi-vector biohazard
o Pulmonary air embolism prevention = Trendelenberg (HOB down) + on left side (to trap air in right side of heart)
o Head Trauma and Seizures – maintain airway = primary concern
o Peptic Ulcers
Feed a Duodenal Ulcer (pain relieved by food)
Starve a gastric ulcer
o Acute Pancreatitis
Fetal position, Bluish discoloration of flanks (Turner’s Sign), Bluish discoloration of pericumbelical
region (Cullen’s Sign), Board like abdomen with guarding
Self digestion of pancreas by trypsin.
o Hold tube feeding if residual > 100mL
o In case of Fire – RACE and PASS
o Check Restraints every 30 minutes – 2 fingers room underneath
o Gullian-Barre Syndrome
Weakness progresses from legs upward – leads to Resp arrest
o Trough draw = ~30 min before scheduled administration
o Peak Draw = 30-60 min after drug administration.
Mental Health and Psychiatry
o Most suicides occur after beginning of improvement with increase in energy levels
o MAOIs
Hypertensive Crisis with Tyramine foods
Nardil, Marplan, Parnate
Need 2 wk gap from SSRIs and TCAs to admin MAOIs
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