HESI Hints & NCLEX Gems

HAnswering NCLEX Questions  Maslow’s Hierarchy of Needs o Physiologic o Safety o Love and Belonging o Esteem o Self-actualization  Nursing Process o Assessment o Diagnosis (Analysis) o Planning o Implementation (treatment) o Evaluation  ABCs o Airway o Breathing o Circulation Normal Values  Hgb o Males 14-18 o Females 12-16  Hct o Males 42-52 o Females 37-47  RBCs o Males 4.7-6.1 million o Females 4.2-5.4 million  WBCs o 4.5-11k  Platelets o 150-400k  PT (Coumadin/Warfarin) o 11-12.5 sec (INR and PT TR = 1.5-2 times normal)  APTT (Heparin) o 60-70 sec (APTT and PTT TR = 1.5-2.5 times normal)  BUN 10-20  Creatinine 0.5-1.2  Glucose 70-110  Cholesterol 200  Bilirubin Newborn 1-12  Phenylalanine o Newborn 2 o Adult 6 '  Na+ 136-145  K+ 3.5-5 o HypoK+  Prominent U waves  Depressed ST segment  Flat T waves o HyperK+  Tall T-Waves  Prolonged PR interval  wide QRS  Ca++ 9-10.5 o Hypocalcemia  muscle spasms  convulsions  cramps/tetany  + Trousseau’s OR + Chvostek’s  prolonged ST interval  prolonged QT segment  Mg+ 1.5-2.5  Cl- 96-106  Phos 3-4.5  Albumin 3.5-5  Spec Gravity 1.005-1.030  Glycosylated Hemoglobin (Hgb A1c): o 4-6% ideal o 7.5% = OK (120 days)  Dilantin TR = 10-20  Lithium TR = 0.5-1.5 Antidotes  Digoxin  Digiband  Coumadin  Vitamin K (Keep PT and INR @ 1-1.5 X normal)  Benzodiazapines  Flumzaemil (Tomazicon)  Magnesium Sulfate  Calcium Gluconate?  Heparin  Protamine Sulfate (Keep APTT and PTT @ 1.5-2.5 X normal)  Tylenol  Mucomist (17 doses + loading dose)  Opiates (narcotic analgesics, heroin, morphine)  Narcan (Naloxone)  Cholinergic Meds (Myesthenic Bradycardia)  Atropine  Methotrexate  Leucovorin Delegation  RN Only o Blood Products (2 RNs must check) o Clotting Factors o Sterile dressing changes and procedures o Assessments that require clinical judgment o Ultimately responsible for all delegated duties  Unlicensed Assistive Personnel o Non-sterile procedures o Precautions & Room Assignments 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 or Ambu-bag for resuscitation  Refrain from giving care if you have skin lesion Droplet (Respiratory) Precautions  Mask  Sepsis  Scarlet Fever  Strep  Fifth Disease (Parvo B19)  Pertussis, Pneumonia, Influenza  Diphtheria, Epiglottitis, Rubella, Rubeola, Meningitis, Mycoplasma, Adenovirus, Rhinovirus  RSV (needs contact precautions too)  TB  Respiratory Isolation Contact Precautions  Universal + Goggles, Mask and Gown No infection patients with immunosuppressed patients Weird Miscellaneous Stuf  Rifampin (for TB) … Rust/orange/red urine and body fluids  Pyridium (for bladder infection) … Orange/red/pink urine  Myesthenia Gravis  Myesthenic Crisis o Weakness with change in vitals (give more meds)  Cholinergic Crisis o Weakness with no change in vitals (reduce meds)  Diabetic Coma vs. Insulin Shock o Give glucose first – If no help, give insulin  Lipitor (statins) in PMs only – No grapefruit juice  Stroke o Tongue points toward side of lesion (paralysis) o Uvula deviates away from the side of lesion (paralysis)  Stay in bed for 3 hours after first ACE Inhibitor dose  Avoid Grapefruit juice with Ca++ Channel Blockers  Anthrax = Multi-vector biohazard  Pulmonary air embolism prevention o Trendelenburg o On left side (to trap air in right side of heart)  Head Trauma and Seizures  Maintain airway  Peptic Ulcers o Feed a Duodenal Ulcer (pain relESI Hints & NCLEX Gems