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NCLEX LPN (study guide)

Terms in this set (202)

do no delegate what you can not eat

E - evaluate
A - assess
T - teach

hyponatremia, hypotension, decreased blood vol, hyperkalemia, hypoglycemia

hypernatremia, hypertension, increased blood vol, hypokalemia, hyperglycemia

elevate veins
dangle arteries

Appearance (all pink, pink and blue, blue (pale)
Pulse (>100, <100, absent)
Grimace (cough, grimace, no response)
Activity (flexed, flaccid, limp)
Respirations (strong cry, weak cry, absent)

Transmission based isolation precautions Airborne

MY - measles
Chicken - chickenpox/ varicella
Hez - herpes zoster/shingles
TB
private room, neg pressure with 6-12 air exchanges/hour, mask (N95 for TB)

Droplet precautions

*Think SPIDERMAN*
S = Sepsis, scarlet fever, streptococcal pharyngitis
P = Parvovirus B19, pneumonia, pertussis
I = Influenza
D = Diphtheria
E = Epiglottitis
R= Rubella
M = Mumps, meningitis, mycoplasma or meningeal pneu.
AN= Adenovirus (private room, mask)
*Droplet requires mask, gown, gloves, mask & goggles*
private room or cohort

contact precautions

MRS WEE
M = Multidrug Resistant Organism
R = Respiratory Infection
S = Skin Infections
W = Wound Infections
E = Enteric Infection (Clostridium Difficile)
E = Eye Infections (Conjunctivitis)

SKIN Infections: V CHIPS

V = Varicella
C = Cutaneous Diphtheriae
H = Herpes's simplex
I = Impetigo
P = Pediculosis
S = Scabies

Air/Pulmonary Embolism

S/S: chest pain, SOB, Tachycardia, Pale/Cyanotic, Sense of Impending Doom
Intervention: Place client on LEFT side and LOWER the HOB.

Woman in Labor w/ NON-Reassuring FHR: S&S and Care

S&S Include: late decelerations, decreased variability, fetal bradycardia, etc.
Care: turn on LEFT SIDE (also give O2, stop Pitocin and increase IV fluids)

Tube Feeding w/ DECREASED LOC: Care

Care Includes: Position pt on right side (this promotes emptying of the stomach) with the HOB elevated (to prevent aspiration)

During Epidural Puncture

After Lumbar Puncture

e(and also oil-based Myelogram)--> pt lies in flat supine (to prevent
headache and leaking of CSF)

Pt w/ heat stroke? _____ with legs ____

lie flat, elevated

during Continuous Bladder Irrigation (CBI)

catheter is taped to thigh so leg should be
kept straight. No other positioning restrictions.

After Myringotomy

position on side of affected ear after surgery (allows drainage of
secretions)

After Cataract Surgery: Care

Care Includes: The patient will sleep on the *unaffected side with a night shield for 1 - 4 weeks.

after Thyroidectomy

low or semi-fowler's position, support head, neck and shoulders.

Infant w/ Spina Bifida

position prone (on abdomen) so that sac does not rupture

Buck's Traction (skin)

elevate foot of bed for counter traction

After total hip replacement

don't sleep on operated side, don't flex hip more than 45-
60 degrees, don't elevate HOB more than 45 degrees. Maintain hip abduction by separating
thighs with pillows.

Knee to chest or Trendelenburg
oxygen 8 to 10 L

Infant w/ Cleft Lip

position on back or in infant seat to prevent trauma to the suture line. while feeding hold in upright position.

To prevent dumping syndrome

(post operative ulcer/stomach surgeries) eat in reclining position. Lie down after meals for 20-30 min. also restrict fluids during meals, low CHO and fiber diet. small, frequent meals.

above knee amputation

elevate for first 24 hours on pillow, position prone daily to provide for hip extension.

Below Knee Amputation (BKA)

Elevate the foot of the bed for the first 24 hours

Position prone daily to provide for hip extension

Detached retina

area of detachment should be in the dependent position

Administration of enema

pt should be left side lying (Sim's) with knee flexed.

After Supratentorial Surgery (incision behind hairline)

elevate HOB 30-45 degrees

After Infratentorial Surgery (incision at nape of neck)

position patient flat & lateral on either side

During internal radiation

on bedrest while implant in place

Autonomic Dysreflexia/Hyperreflexia

S/S pounding headache, profuse sweating, nasal congestion, chills, bradycardia, hypertension. Place client in sitting position (elevate HOB) FIRST!

bedrest with extremities elevated 20 degrees. knees straight, head slightly elevated (modified Trendelenburg)

elevate HOB 30 degrees to decrease intracranial pressure

Peritoneal Dialysis (when outflow is inadequate)

turn pt from side to side BEFORE checking for kinks in tubing

lumbar puncture (LP)

After the procedure, the client should be placed in the supine position for 4-12 hours as prescribed

Demerol, NOT morphine sulfate

Myasthenia Gravis

worsens with exercise and improves with rest

Myasthenia Crisis

a positive reaction to Tensilon---will improve symptoms

Cholinergic Crisis

Caused by excessive medication ---stop giving Tensilon...will make it worse.

Head injury medications

Mannitol (osmotic diuretic)-crystallizes at room temp so ALWAYS use filter needle

prior to liver biopsy it's important to be aware of the lab result for prothrombin time

Ass = Metabolic Acidosis (Diarrhea)

(vomitus) = metabolic alkalosis

Myxedema/hypothyroidism

slowed physical and mental function, sensitivity to cold, dry skin and hair.

Grave's Disease/ hyperthyroidism

accelerated physical and mental function. Sensitivity to heat. Fine/soft hair.

increased temp, pulse and HTN

Post-Thyroidectomy

semi-fowler's. Prevent neck flexion/hyperextension. Trach at bedside

Hypo-parathyroid (CATS)

convulsions, arrhythmias, tetany, spasms, stridor (decreased calcium)

High Ca, low phosphorus diet

Hyper-parathyroid

fatigue, muscle weakness, renal calculi, back and joint pain (increased calcium) give a low calcium high phosphorous diet

increased temp, rapid/weak pulse, increase respiration, hypotension, anxiety. Urine specific gravity >1.030

bounding pulse, SOB, dyspnea, rales/crackles, peripheral edema, HTN, urine specific gravity <1.010. semi fowler's

Diabetes insipidus (decreased ADH)

excessive urine output and thirst, dehydration, weakness, administer Pitressin

SIADH (increased ADH)

change in LOC, decreased deep tendon reflexes, tachycardia. N/V HA administer Declomycin, diuretics

muscle weakness, dysrhythmias, increase K (raisins bananas apricots, oranges, beans, potatoes, carrots, celery)

MURDER Muscle weakness, Urine (olig, anuria) Resp depression, decreased cardiac contractility, ECG changes, reflexes

nausea, muscle cramps, increased ICP, muscular twitching, convulsions. give osmotic diuretics (Mannitol) and fluids

increased temp, weakness, disorientation, delusions, hypotension, tachycardia. give hypotonic solution.

CATS Convulsions, Arrhythmias, Tetany, spasms and stridor

muscle weakness, lack of coordination, abdominal pain, confusion, absent tendon reflexes, shallow respirations, sedative effect on CNS

tremors, tetany, seizures, dysrhythmias, depression, confusion, dysphagia; dig toxicity

depresses the CNS, hypotension, facial flushing, muscle weakness, absent deep
tendon reflexes, shallow respirations, emergency

Addisonian crisis

N/V confusion, abdominal pain, extreme weakness, hypoglycemia, dehydration, decreased BP

Pheochromocytoma

hypersecretion of epi/norepi. persistent HTN, increased HR, hyperglycemia, diaphoresis, tremor, pounding HA; avoid stress, frequent bathing and rest breaks, avoid cold and stimulating foods (surgery to remove tumor)

Neuroleptic Malignant Syndrome (NMS)

- NMS is like S & M
- You get hot (hyperpyrexia)
- stiff (increased muscle tone)
- Sweaty (diaphoresis)
- BP, pulse and resp go up
- Start to drool

never get pregnant with a German (rubella)

I kept forgetting which was dangerous when you're pregnant; regular measles (rubeola), or
German measles (rubella), so remember:
-never get pregnant with a German (rubella)

When drawing up regular insulin & NPH together, remember:

-RN (regular comes before NPH)

Tetrallogy of Fallot

think drop (child drops to floor or squats)
defect, septal
right ventricular hypertrophy
overriding aorta
pulmonary stenosis

MAOI's that are used as antidepressants
pirates take MAOI's when they're depressed

Think pirates say arrrr;
MAOIs used for depression will have an arrr sound in the middle (Parnate, Marplan, Nardil)

Autonomic Dysreflexia

(potentially life threatening emergency!) HOB elevate 90 degrees, loosen constrictive clothing, assess for full bladder or bowel impaction, (trigger) administer antihypertensive (may cause stroke, MI, seizure)

Easy way to remember MAOIs

PANAMA
PA - parnate
NA - nardil
MA- marplan

check pulse, less than 60 hold, check dig levels and potassium levels.

- Tx of GERD and kidney stones
- Watch out for constipation

- Tx of anxiety and also itching
- Watch out for dry mouth, given preop commonly

given for conscious sedation...watch for resp depression and hypotension

PTU and Tapazole

prevention of thyroid storm

Sinemet (carbidopa/levodopa)

tx of Parkinson's
sweat, saliva, urine may turn reddish brown occasionally....causes drowsiness

tx of Parkinson's, Sedative effect also

tx of Parkinson and extrapyramidal effects of other drugs

tx of postop n/v and for nausea associated with gastroenteritis

Timolol (Timoptic)

antibiotic. Don't take if allergic to sulfa drugs...diarrhea common side effect...drink plenty of fluids

Probenecid (Benemid), Colchicine, Allopurinol (Zyloprim)

Apresoline (hydralazine)

tx of HTN or CHF, Report flu-like symptoms, rise slowly from sitting/lying position; take with meals.

tx of irritable bowel....assess for anticholinergic side effects.

Calan (verapamil)

calcium channel blocker: tx of HTN, angina...assess for constipation

tx of duodenal ulcers, coats the ulcer...so take before meals.

tx of asthma or COPD..therap drug level: 10-20

is the antidote to Tylenol and is administered orally

tx of glaucoma, high altitude sickness...don't take if allergic to sulfa drugs

Indocin (NSAID)

Treatment of arthritis (osteo, RA, gouty), bursitis, and tendonitis

tx of hypothyroidism. May take several weeks to take effect...notify doctor of chest pain, take in the AM on empty stomach, could cause hyperthyroidism.

tx of alcohol w/d...don't take alcohol with this...very bad nausea and vomiting can occur.

Oncovin (vincristine)

tx of leukemia, given IV ONLY

tx of scabies and lice...(scabies)apply lotion once and leave on for 8-12 hours...(lice) use the shampoo and leave on for 4 minutes with hair uncovered then rinse with warm water and comb with a fine tooth comb

tx after menopause estrogen replacement

tx of seizures. thera drug level: 10-20

tx of schizophrenia, assess for EPS

tx of ADHD..assess for heart related side effects report immediately...child may need a drug holiday b/c it stunts growth.

dopamine (Intropine)

tx of hypotension, shock, low cardiac output, poor perfusion to vital
organs...monitor EKG for arrhythmias, monitor BP

Have trouble remembering fhr patterns in OB? Think VEAL CHOP

V = variable; C = cord compression caused
E = early decels; H = head compression caused
A = accels; O = okay, no problem
L = late decels; P = placental insufficiency, can't fill

For cord compression, place the mother ______ position

If the cord is prolapsed, (OB)

cover it with sterile saline gauze to prevent drying of the cord and to minimize infection.

For late decels (OB)

turn the mother to her left side, to allow more blood flow to the placenta. For any kind of bad fetal heart rate pattern, you give O2, often by mask...

For any kind of bad fetal heart rate pattern (OB)

you give O2, often by mask...

When doing an epidural anesthesia (OB)

hydration before hand is a priority

Hypotension / Bradypnea/bradycardia (OB)

Major risks and emergencies

NEVER check the monitor or a machine as a FIRST ACTION. ALWAYS assess the CLIENT FIRST! (OB)

for example listen to the fetal heart tones with a stethoscope in NCLEX land

If the baby is a POSTERIOR presentation: (OB)

the sounds are heard at the sides

If the baby is an anterior presentation: (OB)

The sounds are heard closer to the MIDLINE, between the UMBILICUS and the SIDES.

If the baby is breech:

the sounds are high up in the fundus near the umbilicus. If the baby is vertex, they are a little bit above the symphysis pubis.

For Ventilator Alarms - HOLD

HIGH alarm- OBSTRUCTION due to incr. secretions, kink, pt. coughs, gag or bites
LOW PRESSURE alarm-DISCONNECTION or leak in ventilator or in pt. airway cuff, pt. stops spontaneous
breathing

To remember blood sugar?

hot and dry-sugar high (hyperglycemia)
cold and clammy-need some candy (hypoglycemia)

ICP AND SHOCK HAVE OPPOSITE V/S

ICP- Increased BP, decreased pulse, decreased resp
Shock--Decreased BP, increased pulse, increased resp

right sided heart failure caused by left ventricular failure (so pick edema, jvd, if it is a choice.)

Heroin withdrawal neonate

S/S: Irritable and poor sucking

no meat and milk together

pulse area on an infant

Test child for lead poisoning at:

- Around 12 months of age

bananas, potatoes, citrus fruits source of

Cultures are obtained before starting

a pt with leukemia may have

epistaxis due to low platelets

Best way to warm a newborn?

skin to skin contact covered with a blanket on mom

when a pt comes in and is in active labor

first action of nurse is to listen to fetal heart tones/rate

phobic disorders

Use SYSTEMIC DESENSITIZATION

When getting down to two answers, choose

the assessment answer (assess, collect, auscultate, monitor, palpate) over the intervention except in an emergency or distress situation. If one answer has an absolute, discard it. Give priority to answers that deal directly to the patient's body, not the machines/equipment's.

Key words are very important

Avoid answers with absolutes for example:
always, never, must, etc

with lower amputations patient is placed in

small frequent feedings

are better than larger ones

Assessment, teaching, meds, evaluation, unstable patient

cannot be delegated to an UAP

Aminoglycosides (like vancomycin)

cause nephrotoxicity & ototoxicity

IV push should go over..

If the patient is not a child an answer

with family option can be ruled out easily

ARDS (fluids in alveoli) and DIC (disseminated intravascular coagulation) are always:

secondary to something else (another disease process)

Cardinal sign of ARDS

hypoxemia (low oxygen level in tissues).

in pH regulation the 2 organs of concern are

lungs and kidneys

Edema is in the INTERSTITIAL SPACE and NOT in the:

Cardiovascular space

weight is best indicator of

wherever there is sugar (glucose)

aspirin can cause Reye's syndrome (encephalopathy)

when given to children

use Cold for acute pain (eg. Sprain ankle) and Heat for chronic (
rheumatoid arthritis)

Guided imagery is great for?

when patient is in distress

medication administration is rarely a good
choice.

fever and chills are usually present. For the elderly confusion is often present.

Always check for allergies before administering

antibiotics (especially PCN).
Make sure culture and sensitivity has been done before adm. First dose
of antibiotic.

(s/s fluid overload) is Right sided heart failure caused by pulmonary disease, occurs with bronchitis or emphysema

COPD is chronic, pneumonia is acute.

bronchitis and emphysema are both COPD

in COPD patients the baroreceptors that detect the CO2 level are destroyed

therefore, O2 level must be low, because high O2 concentration blows the patients stimulus for breathing

epi always given in

Prednisone toxicity (cushing's syndrome):

Buffalo hump, moon face, hyperglycemia, hypertension

4 options for cancer management:

chemo, radiation, surgery, allow to
die with dignity.

Neutropenic patients

no live vaccines, no fresh fruits, no flowers should be used

chest tubes are placed in the

dead heart tissue present.

angina (low oxygen to heart tissues) =

no dead heart tissues.

Mevacor (anticholesterol) must be given with:

With evening meal if it is QD (per day)

Preload effects:

Amount of blood that goes to the RIGHT ventricle

Afterload is the:

Resistance that the blood has to overcome when leaving the heart

Calcium Channel Blockers

affects the afterload

For a CABG operation, when the GREAT SAPHENOUS vein is taken it is:

turned inside out due to the valves that are inside

unstable angina

not relieved by nitro

DEAD tissues can NOT have:

PVCs; if left untreated, PVCs can lead to VF

1 T(tablespoon)= ___ t = ___ml

1 quart = ____ pints

1 pint = ____ cups

1 gr (grain) = ___ mg

1 g (gram) = ______ mg

To convert Centigrade to F

F= C+40, multiply 9/5 and substract 40

convert farenheit to C

C = F=40, multiply 5/9 and subtract 40

Angiotensin II in the lungs

potent vasodilator

attracts sodium

REVERSE AGENTS FOR TOXICITY
heparin

protamine sulfate

REVERSE AGENTS FOR TOXICITY - coumadin

REVERSE AGENTS FOR TOXICITY - ammonia

REVERSE AGENTS FOR TOXICITY - acetaminophen

REVERSE AGENTS FOR TOXICITY - iron

REVERSE AGENTS FOR TOXICITY - digitoxin, digoxin

REVERSE AGENTS FOR TOXICITY - alcohol withdraw

is an opioid analgesic used to detoxify/treat pain in narcotic addicts

potentiates dig toxicity

prevents platelet aggregation

are elevated when patient is on coumadin

decreases w/dysrhythmias

med of choice for Vtach

med of choice for SVT

adenosine or adenocard

med of choice for asystole

Med of choice for CHF

ACE Inhibitor (-pril)

med of choice for anaphylactic shock

Med of choice for Status Epilepticus

Med of choice for bipolar

Amiodarone is effective in both

ventricular & atrial complications

. S3 sound is normal in ______. Is not normal in ________.

give carafate, GI med, before

meals to coat stomach

is given prophylactically to prevent stress ulcers

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