Study Guide
1. ABCs (Airway, Breathing, Circulation)
2. When in distress DO NOT ASSESS! Unless 2nd hand information is received.
3. Scenario
Expected outcome with Disease Process: Continue to monitor & Document finding
Unexpected finding with Disease Process: Nursing intervention that must make a
difference & Call HCP
4. Mini Maslow’s
1) ABCs (& Pain unrelieved by meds)
2) Safety
3) Comfort (Pain)
4) Psychological
5) Social
6) Spiritual
5. STAT words → Pick the answer that failing to do so will kill or cause great harm
● Highest Priority
● Most Important
● Immediate Action
6. *Least Invasive First*
7. Secondhand Info → Any time you have 2nd hand info, the right answer is ASSESS
∙ UAP ∙ Family
∙ Labs ∙ EMR
∙ EKG ∙ BP machine
8. Never ever take away the coping mechanism a patient uses during a crisis, except if the
mechanism puts the patient or others @ risk
9. Eliminate answer choices & DNR
10. Never withhold Tx! If you are left with two answer choices and the options are to Tx, or
watch the patient, Pick Tx!
11. Anytime there is a reversal from the norm, you must worry!
Ex: rebound tenderness (pain after you relieve pressure)
,12. Assign Stable Patients to:
∙ UAP ∙ LPN ∙ New nurse
∙ Graduate Nurse ∙ Float Nurse ∙ Travel nurse
13. Anytime you see excessive findings, that is not normal!
14. Always empower your patient
15. If a question has “”, pick an answer that has what they’re feeling & not what they’re
saying
16. 3 R’s of Psych
1) Reality – Functional psych pt.
2) Reassure – pt. with Delirium
3) Redirect – pt. with Dementia
Default Answers
2 Give meds either 1 hour before meal or 2 hours after meal
3 Give antacids 1 hour before med or 4 hours after med
4 When in doubt pick K (potassium)
5 2– 3 L of fluids
6 When in doubt pick answer that has you stay with patient
7 Anytime you see restless & ↓ level of consciousness = early sign - PICK
8 Head of Bead → 30-45 degrees for any neuro patient
9 Elderly with acute onset confusion → UTI
10 Secretions will turn Orange/Red for meds
,11 Anytime you have GI problem/exacerbation = NPO
11. All surgeries RISK:
1st 24 hrs. – bleeding
48 hrs. – infection
12 Check daily weights if it is a fluid problem
13 Lateral position for maternity
14 Remove answer choices that are ‘absolutes’
Rules for Delegation
RN ASSIGNMENT = Do not delegate what you can E.A.T: Evaluate Assess Teach
● Cannot delegate assessment, teaching, or nursing judgement
LPN/LVN ASSIGNMENT
● Assign stable with expected outcomes
UAP ASSIGNMENT
● Delegate standard, unchanging procedures
Five Rights of Delegation
RIGHT TASK – scope of practice, stable client
RIGHT CIRCUMSTANCES – workload
RIGHT PERSON – scope of practice
RIGHT COMMUNICATION – specific task to be
performed, expected results, follow-up communication
RIGHT SUPERVISION – clear directions, intervene if
necessary
Therapeutic Communication Tips
DO: DO NOT:
Do respond to feeling tone ● Do not ask “why” questions - NEVER pick WHY
Do provide information ● Do not ask ‘yes/no’ questions, except in the case of possible
Do focus on the client self-harm
Do use silence ● Do not focus on the nurse
Do use presence ● Do not explore
● Do not say, “Don’t worry!”
Who Do You See First?
, Consider:
∙ Unstable vs. Stable ∙ Acute vs. Chronic
∙ Unexpected vs. Expected ∙ Actual vs. Potential
∙ ABCs
Common Traps
∙ Do not ask “Why?” ∙ Do not ‘do nothing.’
∙ Do not leave the client. ∙ Do not read into the question
∙ Do not persuade the client. ∙ Do not pass the buck.
∙ Do not say, “Don’t worry!”
Strategies
● Only use textbook nursing – textbook knowledge
● Pain is psychosocial, unless, it is severe, acute, & unrelenting
● If it is a position question, is it going to prevent or promote something – position,
prevent, promote
● Teaching/learning – use T/F on each answer – same strategy for SATA questions
● Risk Questions – use Risk Factors
● If the answers have an absolute in them, do not pick them
● Question that have the phrase ‘And Then’ – did they miss something
Important Lab Values
WBC 4K – 11K
RBC 4–6
Hgb 12 – 16, 0r 12-18
Hct 36 – 48, or 37-52
Plt 150K – 400K
BUN 8 – 20, or 7-22
Cr/Lithiu 0.6 – 1.2
m
Urine 85 – 135,
Clearanc (GFR)=maintain
e above 60
Uric Acid 250 – 750 mg
Na 135 – 145
Cl 98 – 106
Ca 8.5 – 10.5
K 3.5 – 5.0
PO 2.5 – 4.5g
Mag 1.5 – 2.5, 4-7 if
1. ABCs (Airway, Breathing, Circulation)
2. When in distress DO NOT ASSESS! Unless 2nd hand information is received.
3. Scenario
Expected outcome with Disease Process: Continue to monitor & Document finding
Unexpected finding with Disease Process: Nursing intervention that must make a
difference & Call HCP
4. Mini Maslow’s
1) ABCs (& Pain unrelieved by meds)
2) Safety
3) Comfort (Pain)
4) Psychological
5) Social
6) Spiritual
5. STAT words → Pick the answer that failing to do so will kill or cause great harm
● Highest Priority
● Most Important
● Immediate Action
6. *Least Invasive First*
7. Secondhand Info → Any time you have 2nd hand info, the right answer is ASSESS
∙ UAP ∙ Family
∙ Labs ∙ EMR
∙ EKG ∙ BP machine
8. Never ever take away the coping mechanism a patient uses during a crisis, except if the
mechanism puts the patient or others @ risk
9. Eliminate answer choices & DNR
10. Never withhold Tx! If you are left with two answer choices and the options are to Tx, or
watch the patient, Pick Tx!
11. Anytime there is a reversal from the norm, you must worry!
Ex: rebound tenderness (pain after you relieve pressure)
,12. Assign Stable Patients to:
∙ UAP ∙ LPN ∙ New nurse
∙ Graduate Nurse ∙ Float Nurse ∙ Travel nurse
13. Anytime you see excessive findings, that is not normal!
14. Always empower your patient
15. If a question has “”, pick an answer that has what they’re feeling & not what they’re
saying
16. 3 R’s of Psych
1) Reality – Functional psych pt.
2) Reassure – pt. with Delirium
3) Redirect – pt. with Dementia
Default Answers
2 Give meds either 1 hour before meal or 2 hours after meal
3 Give antacids 1 hour before med or 4 hours after med
4 When in doubt pick K (potassium)
5 2– 3 L of fluids
6 When in doubt pick answer that has you stay with patient
7 Anytime you see restless & ↓ level of consciousness = early sign - PICK
8 Head of Bead → 30-45 degrees for any neuro patient
9 Elderly with acute onset confusion → UTI
10 Secretions will turn Orange/Red for meds
,11 Anytime you have GI problem/exacerbation = NPO
11. All surgeries RISK:
1st 24 hrs. – bleeding
48 hrs. – infection
12 Check daily weights if it is a fluid problem
13 Lateral position for maternity
14 Remove answer choices that are ‘absolutes’
Rules for Delegation
RN ASSIGNMENT = Do not delegate what you can E.A.T: Evaluate Assess Teach
● Cannot delegate assessment, teaching, or nursing judgement
LPN/LVN ASSIGNMENT
● Assign stable with expected outcomes
UAP ASSIGNMENT
● Delegate standard, unchanging procedures
Five Rights of Delegation
RIGHT TASK – scope of practice, stable client
RIGHT CIRCUMSTANCES – workload
RIGHT PERSON – scope of practice
RIGHT COMMUNICATION – specific task to be
performed, expected results, follow-up communication
RIGHT SUPERVISION – clear directions, intervene if
necessary
Therapeutic Communication Tips
DO: DO NOT:
Do respond to feeling tone ● Do not ask “why” questions - NEVER pick WHY
Do provide information ● Do not ask ‘yes/no’ questions, except in the case of possible
Do focus on the client self-harm
Do use silence ● Do not focus on the nurse
Do use presence ● Do not explore
● Do not say, “Don’t worry!”
Who Do You See First?
, Consider:
∙ Unstable vs. Stable ∙ Acute vs. Chronic
∙ Unexpected vs. Expected ∙ Actual vs. Potential
∙ ABCs
Common Traps
∙ Do not ask “Why?” ∙ Do not ‘do nothing.’
∙ Do not leave the client. ∙ Do not read into the question
∙ Do not persuade the client. ∙ Do not pass the buck.
∙ Do not say, “Don’t worry!”
Strategies
● Only use textbook nursing – textbook knowledge
● Pain is psychosocial, unless, it is severe, acute, & unrelenting
● If it is a position question, is it going to prevent or promote something – position,
prevent, promote
● Teaching/learning – use T/F on each answer – same strategy for SATA questions
● Risk Questions – use Risk Factors
● If the answers have an absolute in them, do not pick them
● Question that have the phrase ‘And Then’ – did they miss something
Important Lab Values
WBC 4K – 11K
RBC 4–6
Hgb 12 – 16, 0r 12-18
Hct 36 – 48, or 37-52
Plt 150K – 400K
BUN 8 – 20, or 7-22
Cr/Lithiu 0.6 – 1.2
m
Urine 85 – 135,
Clearanc (GFR)=maintain
e above 60
Uric Acid 250 – 750 mg
Na 135 – 145
Cl 98 – 106
Ca 8.5 – 10.5
K 3.5 – 5.0
PO 2.5 – 4.5g
Mag 1.5 – 2.5, 4-7 if
