NCLEX MEDSURG MASTER STUDY GUIDE
NCLEX/MedSurg Master Study Guide
Nursing Process:
A - assessment
D - diagnosis
O - outcome planning (specific, measurable, timely)
Ex. The patient will walk 300 ft in the hallway by the end of the shift (3pm)
P - planning
Planning is done WITH patient, not FOR them. Let them assist in making goals that they
see as doable
I - intervention
E - evaluation
Reflecting on whether the goal was met/ what could be changed to help the pt. Reach it
not evaluating **ourselves** we are evaluating whether or not the goal was MET
Nursing Virtues:
Beneficence - “do good”
Non maleficence - “do no harm”
Veracity - telling the truth, never lying or trying to deceive a patient
If you make a med error, if a patient asks you about their disease
Fidelity - keeping your promises
Autonomy - pt. Is allowed (and supported) to make their own decisions
Choosing treatment plans, right to advance directives, DNR orders, etc.
Justice - providing fair care to all
Providing equal care to patients no matter what (age, sex, race, LGBT, religion, disease)
Confidentiality - keeping things between you and the patient
If a patient tells you something, it should remain between the two of you
The ONLY times you can break confidentiality are when the patient’s safety is involved
(ex. Pt. is going to commit suicide, mandatory reporting of elder abuse, etc)
Privacy - pt. Is entitled to their own personal privacy
Closing the door /curtain when they are physically exposed/leaving the room if the
patient is on the toilet
Normal Lab Values:
Digoxin 0.5-2, anything above 2 will give nausea, vomiting, diarrhea, and VISUAL
disturbances (yellow halo around anything they are looking at)
If the patient is hypokalemic (low potassium), makes it easier for them to go into Dig.
toxicity
Hold digoxin if their heart rate is below 60 bpm
Lithium - 0.5-1.5, hold for anything higher! Tremors, confusion, seizures etc.
Typically used for bipolar disorder
Never double up 22 on lithium doses if you miss one -- safety!
Lithium messes with their sodium! They need to stay stable with their sodium intake and
consult their doctor before vigorous work outs / saunas / etc. because sweat can cause
them to lose too much sodium. When they lose sodium, it makes it easier for lithium
toxicity to occur
Phenytoin/Dilantin 10-20
Used most often for seizure disorders
Blood levels have to monitored over time to adjust dosage -- pt. Gets frequent lab draws
Phenytoin reaction can cause anemia - dyspnea, fatigue, paleness, rashes, swelling and
bleeding of the gums.
BUN: 10-20, indicative of kidney function, monitor for nephrotoxic drugs
Creatinine: 0.6-1.3, indicative of kidney function, monitor for nephrotoxic drugs
,INR (Warfarin) normal 1-2, on warfarin want it to be 2-3 to prevent clots
PT (Warfarin) normal 11-13 seconds,want it to be 1.5-2x longer than that
aPTT (Heparin) (remember 2 T’s in H) normal 30-45 seconds, want it to be 1.5-2.5x longer than
that. <45sec =clots!
Hgb 12-18%
HCt female: 37-47%, male: 42-52%
In pregnancy, H&H can **appear** lower because the woman’s plasma volume is
expanding -- does not mean they are necessarily bleeding if H&H dips a little bit
CVP (central venous pressure, in the heart) 2-6, low CVP is dehydration, high CVP is fluid
overload
High CVP = rales in lungs, JVD, dyspnea, tachycardia
Low CVP = shock, signs of dehydration
Platelets 150,000-400,000, below 150 we are worried about bleeding - bleeding precautions!
ANC (Absolute neutrophil count) - ~2200-7000
Minimum urine in an hour: 30ml/hr
GFR (glomerular filtration rate): should be above 60 with healthy kidneys
WBC’s: 4,000-11,000
Sodium: 135-145 - low/high sodium causes neuro problems = confusion, altered LOC, coma
ALL things potassium:
Potassium: 3.5-5 -- altered potassium = HEART Dysrhythmias, mainly V-tach
Foods with a lot of potassium: bananas, sweet potatoes
We NEVER give potassium via IV push, it can kill the person!!
K+ always given on IV pump, needs to be SLOW over 2-4 HOURS so that we don’t
change their K+ too quickly; never more than 10 mEq/hr
If patient has hyperkalemia - Give IV insulin and then immediately give IV dextrose -
forces potassium back into cells so it is not floating around in the blood causing
problems
Hyperkalemia: HIGH potassium = peaked T waves, wide QRS, wide PR (everything is
UP)
Hypokalemia: LOW potassium = U wave at the end, depressed “low waves”, muscle
cramps = especially CALF -- if pt has low potassium they can go into torsades = BAD
Also tell patient to avoid “salt substitutes” in their diet because those oftentimes contain
potassium in them instead
Calcium:
normal 8.6-10.2
Low calcium = crazy muscles!
Laryngospasms*** priority because this is your throat! Airway compromise!
Positive chvostek / trousseau’s sign
Seizures
Muscle tightness and cramping
Hyperactive bowel sounds, diarrhea
When to worry about low calcium?? After a thyroidectomy!! The parathyroid glands
(which break down bone and put calcium into the blood) are on the thyroid….. So
sometimes during surgery the parathyroid glands can be removed with the thyroid!! This
will cause low low calcium = look for the low calcium signs when they get back from
thyroid surgery!
, High calcium = acts as a sedative
Low grade deep tendon reflexes
Hypoactive bowel sounds
Respiratory depression
Drug Antidotes
Warfarin -Vitamin K (also found in leafy green vegetables)
Heparin - Protamine sulfate
Tylenol - N-Acetylcystine (Mucomyst) 17 doses and a loading dose
Digoxin - Digibind
Iron - Desferoxamine, binds to iron in the blood and excretes it so you don’t go into metabolic
acidosis
Cholinergic drugs - atropine
Opioids - naloxone (Narcan) -- can be given nasal spray / IV/ IO
Drugs & Drug Tips
Buccal medications - go onto the mucosa of the cheek
You don’t want them to swallow it or take it out - leave the medication on the cheek until
it dissolves completely
May tingle or burn a little bit - this is normal
Extended release capsules - ex. Toprol XL, aspirin- ER.
Cannot chew, break, split the capsule etc.
If person cannot swallow, need to call MD to change the order. Do NOT alter the
extended release medication because it will alter absorption
Salmeterol inhaler = maintenance inhaler!
Use everyday regardless of whether you feel symptomatic
Not used in emergencies, sudden asthma exacerbation -- always reach for albuterol
“Statin” meds - ex. Atorvastatin, Simvastatin. used to lower cholesterol and triglycerides
We want to lower the LDL cholesterol
Statin’s lower cholesterol by acting on the liver = potential for liver damage!
If they have elevated AST, ALT but lowered trigs/cholesterol = think statins
Steroids - ex. Prednisone. NEVER stop steroids suddenly! Patient needs to taper off their
steroids slowly so there are no complications
Long-term steroid use has a lot of side effects:
Weight gain - Moon face, cushy neck
Hirsutism - abnormal hair growth
Increased acne
Delayed wound healing, increased risk of infection
GI ulcers
High blood pressure, high blood sugar
Spironolactone - potassium SPARING diuretic, monitor their K+ VERY closely -could get high
We do NOT want them to increase intake of potassium
Do not give replacement Meq’s of potassium with spirinolactone! Ex. If they are ordered
for spirinolactone and 40meq’s of potassium = CALL MD, question order
They also shouldn’t use “salt substitutes” because they contain potassium too
Tetracycline/ Doxycycline Antibiotics:
Always take on empty stomach for best absorption
CANNOT take when pregnant
Photosensitivity - make sure you wear sunscreen outside
Drink plenty of fluids throughout the day
, Can interfere with your birth control! Use multiple methods of birth control
WAIT 2 hours before taking anything with iron or calcium
Give IRON with ORANGE JUICE
Iron is well absorbed with vitamin C
Do NOT give Iron with any calcium products (milk, dairy, antacids, etc.) because it
reduces absorption
MAOI’s: you cannot have a diet high in TYRAMINE because it will cause blood pressure to
skyrocket = hypertensive crisis
What kinds of foods are high in tyramine? Avocados, beer, blue cheese, meats like
salami, bologna, processed foods etc. teas cokes and coffees too (caffeine)
ALSO - no over the counter cold medications with MAOI’s
Drugs - “Going to PANAMA” - Parnate, Nardil, Marplan
Warfarin/Coumadin: if on warfarin, INR should be between 2-3 to be therapeutic
Patient has to have blood levels checked frequently
Intake of vitamin K needs to be consistent, do NOT increase/decrease leafy green
veggies
NEVER change the dosage of warfarin on your own or double up on doses
Bleeding precautions
ONLY electric razors - can bleed profusely if using regular razor
Soft toothbrush bristles
Limit unnecessary needle sticks, blood draws, tubes/drains
No aspirin, No NSAIDs - increases risk of bleed
Treat constipation early -- give stool softeners to prevent straining because they
can cause a bleed if they push too hard and stool is hard
Inhaled Corticosteroids:
Risk of thrush (fungal infection) in the mouth
Make sure you rinse your mouth out and brush teeth after using inhaler
Always give the bronchodilator first (albuterol) to open the airway, then the steroid! We
want it to get down into the lungs
Inhaling corticosteroids - it is NORMAL for pt. To feel nervous, have heart racing feeling,
tachycardia -- does not mean something is wrong
Propofol - used for sedation; CANNOT be given by general floor nurses! Immediately question
it if the doctor asks you to give propofol on a general floor
Disulfiram - for getting off alcohol
Cannot use ANY product with alcohol in it - even cooked foods/ mouthwashes
If you stop the med, wait at least two weeks before having any alcohol products
Avoid chocolate and caffeine too
Still need to attend therapy sessions! This is not a cure for alcoholism
Donepezil - for confusion
Notify MD if they are throwing up coffee ground vomit = bleeding!
Alendronate - take on empty stomach but with FULL glass of water to get it to go down and sit
up for at least 30 minutes after taking it
Used for osteoporosis, it’s a bisphosphonate
IV calcium - give VERY slowly, can cause cardiac arrest!
Never give more than 1-2ml/min
MMR vaccine - given SUBQ, not IM
MMR not given if allergic to egg or gelatin because MMR is cultured in egg
Epoetin - stimulates bone marrow to make more red blood cells!
Reduces the chance that the patient will need a blood transfusion
NCLEX/MedSurg Master Study Guide
Nursing Process:
A - assessment
D - diagnosis
O - outcome planning (specific, measurable, timely)
Ex. The patient will walk 300 ft in the hallway by the end of the shift (3pm)
P - planning
Planning is done WITH patient, not FOR them. Let them assist in making goals that they
see as doable
I - intervention
E - evaluation
Reflecting on whether the goal was met/ what could be changed to help the pt. Reach it
not evaluating **ourselves** we are evaluating whether or not the goal was MET
Nursing Virtues:
Beneficence - “do good”
Non maleficence - “do no harm”
Veracity - telling the truth, never lying or trying to deceive a patient
If you make a med error, if a patient asks you about their disease
Fidelity - keeping your promises
Autonomy - pt. Is allowed (and supported) to make their own decisions
Choosing treatment plans, right to advance directives, DNR orders, etc.
Justice - providing fair care to all
Providing equal care to patients no matter what (age, sex, race, LGBT, religion, disease)
Confidentiality - keeping things between you and the patient
If a patient tells you something, it should remain between the two of you
The ONLY times you can break confidentiality are when the patient’s safety is involved
(ex. Pt. is going to commit suicide, mandatory reporting of elder abuse, etc)
Privacy - pt. Is entitled to their own personal privacy
Closing the door /curtain when they are physically exposed/leaving the room if the
patient is on the toilet
Normal Lab Values:
Digoxin 0.5-2, anything above 2 will give nausea, vomiting, diarrhea, and VISUAL
disturbances (yellow halo around anything they are looking at)
If the patient is hypokalemic (low potassium), makes it easier for them to go into Dig.
toxicity
Hold digoxin if their heart rate is below 60 bpm
Lithium - 0.5-1.5, hold for anything higher! Tremors, confusion, seizures etc.
Typically used for bipolar disorder
Never double up 22 on lithium doses if you miss one -- safety!
Lithium messes with their sodium! They need to stay stable with their sodium intake and
consult their doctor before vigorous work outs / saunas / etc. because sweat can cause
them to lose too much sodium. When they lose sodium, it makes it easier for lithium
toxicity to occur
Phenytoin/Dilantin 10-20
Used most often for seizure disorders
Blood levels have to monitored over time to adjust dosage -- pt. Gets frequent lab draws
Phenytoin reaction can cause anemia - dyspnea, fatigue, paleness, rashes, swelling and
bleeding of the gums.
BUN: 10-20, indicative of kidney function, monitor for nephrotoxic drugs
Creatinine: 0.6-1.3, indicative of kidney function, monitor for nephrotoxic drugs
,INR (Warfarin) normal 1-2, on warfarin want it to be 2-3 to prevent clots
PT (Warfarin) normal 11-13 seconds,want it to be 1.5-2x longer than that
aPTT (Heparin) (remember 2 T’s in H) normal 30-45 seconds, want it to be 1.5-2.5x longer than
that. <45sec =clots!
Hgb 12-18%
HCt female: 37-47%, male: 42-52%
In pregnancy, H&H can **appear** lower because the woman’s plasma volume is
expanding -- does not mean they are necessarily bleeding if H&H dips a little bit
CVP (central venous pressure, in the heart) 2-6, low CVP is dehydration, high CVP is fluid
overload
High CVP = rales in lungs, JVD, dyspnea, tachycardia
Low CVP = shock, signs of dehydration
Platelets 150,000-400,000, below 150 we are worried about bleeding - bleeding precautions!
ANC (Absolute neutrophil count) - ~2200-7000
Minimum urine in an hour: 30ml/hr
GFR (glomerular filtration rate): should be above 60 with healthy kidneys
WBC’s: 4,000-11,000
Sodium: 135-145 - low/high sodium causes neuro problems = confusion, altered LOC, coma
ALL things potassium:
Potassium: 3.5-5 -- altered potassium = HEART Dysrhythmias, mainly V-tach
Foods with a lot of potassium: bananas, sweet potatoes
We NEVER give potassium via IV push, it can kill the person!!
K+ always given on IV pump, needs to be SLOW over 2-4 HOURS so that we don’t
change their K+ too quickly; never more than 10 mEq/hr
If patient has hyperkalemia - Give IV insulin and then immediately give IV dextrose -
forces potassium back into cells so it is not floating around in the blood causing
problems
Hyperkalemia: HIGH potassium = peaked T waves, wide QRS, wide PR (everything is
UP)
Hypokalemia: LOW potassium = U wave at the end, depressed “low waves”, muscle
cramps = especially CALF -- if pt has low potassium they can go into torsades = BAD
Also tell patient to avoid “salt substitutes” in their diet because those oftentimes contain
potassium in them instead
Calcium:
normal 8.6-10.2
Low calcium = crazy muscles!
Laryngospasms*** priority because this is your throat! Airway compromise!
Positive chvostek / trousseau’s sign
Seizures
Muscle tightness and cramping
Hyperactive bowel sounds, diarrhea
When to worry about low calcium?? After a thyroidectomy!! The parathyroid glands
(which break down bone and put calcium into the blood) are on the thyroid….. So
sometimes during surgery the parathyroid glands can be removed with the thyroid!! This
will cause low low calcium = look for the low calcium signs when they get back from
thyroid surgery!
, High calcium = acts as a sedative
Low grade deep tendon reflexes
Hypoactive bowel sounds
Respiratory depression
Drug Antidotes
Warfarin -Vitamin K (also found in leafy green vegetables)
Heparin - Protamine sulfate
Tylenol - N-Acetylcystine (Mucomyst) 17 doses and a loading dose
Digoxin - Digibind
Iron - Desferoxamine, binds to iron in the blood and excretes it so you don’t go into metabolic
acidosis
Cholinergic drugs - atropine
Opioids - naloxone (Narcan) -- can be given nasal spray / IV/ IO
Drugs & Drug Tips
Buccal medications - go onto the mucosa of the cheek
You don’t want them to swallow it or take it out - leave the medication on the cheek until
it dissolves completely
May tingle or burn a little bit - this is normal
Extended release capsules - ex. Toprol XL, aspirin- ER.
Cannot chew, break, split the capsule etc.
If person cannot swallow, need to call MD to change the order. Do NOT alter the
extended release medication because it will alter absorption
Salmeterol inhaler = maintenance inhaler!
Use everyday regardless of whether you feel symptomatic
Not used in emergencies, sudden asthma exacerbation -- always reach for albuterol
“Statin” meds - ex. Atorvastatin, Simvastatin. used to lower cholesterol and triglycerides
We want to lower the LDL cholesterol
Statin’s lower cholesterol by acting on the liver = potential for liver damage!
If they have elevated AST, ALT but lowered trigs/cholesterol = think statins
Steroids - ex. Prednisone. NEVER stop steroids suddenly! Patient needs to taper off their
steroids slowly so there are no complications
Long-term steroid use has a lot of side effects:
Weight gain - Moon face, cushy neck
Hirsutism - abnormal hair growth
Increased acne
Delayed wound healing, increased risk of infection
GI ulcers
High blood pressure, high blood sugar
Spironolactone - potassium SPARING diuretic, monitor their K+ VERY closely -could get high
We do NOT want them to increase intake of potassium
Do not give replacement Meq’s of potassium with spirinolactone! Ex. If they are ordered
for spirinolactone and 40meq’s of potassium = CALL MD, question order
They also shouldn’t use “salt substitutes” because they contain potassium too
Tetracycline/ Doxycycline Antibiotics:
Always take on empty stomach for best absorption
CANNOT take when pregnant
Photosensitivity - make sure you wear sunscreen outside
Drink plenty of fluids throughout the day
, Can interfere with your birth control! Use multiple methods of birth control
WAIT 2 hours before taking anything with iron or calcium
Give IRON with ORANGE JUICE
Iron is well absorbed with vitamin C
Do NOT give Iron with any calcium products (milk, dairy, antacids, etc.) because it
reduces absorption
MAOI’s: you cannot have a diet high in TYRAMINE because it will cause blood pressure to
skyrocket = hypertensive crisis
What kinds of foods are high in tyramine? Avocados, beer, blue cheese, meats like
salami, bologna, processed foods etc. teas cokes and coffees too (caffeine)
ALSO - no over the counter cold medications with MAOI’s
Drugs - “Going to PANAMA” - Parnate, Nardil, Marplan
Warfarin/Coumadin: if on warfarin, INR should be between 2-3 to be therapeutic
Patient has to have blood levels checked frequently
Intake of vitamin K needs to be consistent, do NOT increase/decrease leafy green
veggies
NEVER change the dosage of warfarin on your own or double up on doses
Bleeding precautions
ONLY electric razors - can bleed profusely if using regular razor
Soft toothbrush bristles
Limit unnecessary needle sticks, blood draws, tubes/drains
No aspirin, No NSAIDs - increases risk of bleed
Treat constipation early -- give stool softeners to prevent straining because they
can cause a bleed if they push too hard and stool is hard
Inhaled Corticosteroids:
Risk of thrush (fungal infection) in the mouth
Make sure you rinse your mouth out and brush teeth after using inhaler
Always give the bronchodilator first (albuterol) to open the airway, then the steroid! We
want it to get down into the lungs
Inhaling corticosteroids - it is NORMAL for pt. To feel nervous, have heart racing feeling,
tachycardia -- does not mean something is wrong
Propofol - used for sedation; CANNOT be given by general floor nurses! Immediately question
it if the doctor asks you to give propofol on a general floor
Disulfiram - for getting off alcohol
Cannot use ANY product with alcohol in it - even cooked foods/ mouthwashes
If you stop the med, wait at least two weeks before having any alcohol products
Avoid chocolate and caffeine too
Still need to attend therapy sessions! This is not a cure for alcoholism
Donepezil - for confusion
Notify MD if they are throwing up coffee ground vomit = bleeding!
Alendronate - take on empty stomach but with FULL glass of water to get it to go down and sit
up for at least 30 minutes after taking it
Used for osteoporosis, it’s a bisphosphonate
IV calcium - give VERY slowly, can cause cardiac arrest!
Never give more than 1-2ml/min
MMR vaccine - given SUBQ, not IM
MMR not given if allergic to egg or gelatin because MMR is cultured in egg
Epoetin - stimulates bone marrow to make more red blood cells!
Reduces the chance that the patient will need a blood transfusion
