Revised 37-page NCLEX 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 o
Continue to monitor o Document finding
• Unexpected finding with Disease Process o
Nursing intervention that must make a
difference o 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’re left with two answer choices and the options are to Tx, or watch the patient,
Pick Tx!
11. Anytime there’s a reversal from the norm, you must worry!
Ex: rebound tenderness (pain after you relieve pressure)
12. Stable Patients
∙ UAP ∙ LPN ∙ New nurse
∙ Graduate Nurse ∙ Float Nurse ∙ Travel nurse
13. Anytime you see excessive findings, That’s 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 patient
2) Reassure – Delirium
1
3) Redirect – Dementia
Default Answers
1. Give meds either 1 hour before meal or 2 hours after meal
2. Give antacids 1 hour before med or 4 hours after med
3. When in doubt pick K (potassium)
4. 2 – 3 L of fluids
5. When in doubt pick answer that has you stay with patient
6. Anytime you see restless & ↓ level of consciousness = early sign always pick
7. Head of Bead → 30-45 degrees for any neuro patient
, 1
3) Redirect – Dementia
Default Answers
1. Give meds either 1 hour before meal or 2 hours after meal
2. Give antacids 1 hour before med or 4 hours after med
3. When in doubt pick K (potassium)
4. 2 – 3 L of fluids
5. When in doubt pick answer that has you stay with patient
6. Anytime you see restless & ↓ level of consciousness = early sign always pick
7. Head of Bead → 30-45 degrees for any neuro patient
8. Elderly with acute onset confusion → UTI
9. Secretions will turn Orange/Red for meds
10. Anytime you have GI problem/exacerbation = NPO
11. All surgeries
1st 24 hrs – bleeding
48 hrs – infection
12. Check daily weights if it’s a fluid problem
13. Lateral position for maternity
14. Remove answer choices that are ‘absolutes’
Kaplan NCLEX Strategies
Kaplan RN Decision Tree
Step 1 – Can you identify the topic of the question
Step 2 – Are the answers assessment (get data) or implementation (to effect change)?
Step 3 – Apply Maslow: Are the answers physical or psychosocial? (Physical trumps psychosocial)
Step 4 – Are the answer choices related to ABCs?
Step 5 – What is the outcome of each of the remaining answers?
Rules for Delegation
RN ASSIGNMENT
● Cannot delegate assessment, teaching, or nursing judgement EAT, or planning 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:
2
● Do respond to feeling tone ● Do not ask ‘why’ questions
● Do provide information ● Do not ask ‘yes/no’ questions, except in the case of possible self-harm
● Do focus on the client ● Do not focus on the nurse
● Do use silence ● Do not explore
● Do use presence ● Do not say, “Don’t worry!”
Who Do You See First?
Consider:
,DO: DO NOT:
2
● Do respond to feeling tone ● Do not ask ‘why’ questions
● Do provide information ● Do not ask ‘yes/no’ questions, except in the case of possible self-harm
● Do focus on the client ● Do not focus on the nurse
● Do use silence ● Do not explore
● Do use presence ● 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 NCLEX 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 assignments to someone else
∙ Do not say, “Don’t worry!”
Strategies
● Only use textbook nursing – textbook knowledge
● Pain is psychosocial, unless, it’s severe, acute, & unrelenting
● If it’s a position question, is it going to prevent or promote something – position, prevent, promote
● Teaching/learning – use T/F on each answer
● 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
3
Important Lab Values
, 3
Important Lab Values
Therapeutic PTT: 1.5 – 2x the normal value (46 – 76 Seconds)
Cholesterol
HDL
LDL
Therapeutic Ranges
Dilantin Theophylline
Acetaminophen
Digoxin 2.0
Albumin level 3.5 to 5.5
Acid-Base Balance
From the ass (diarrhea) –Metabolic Acidosis
From the mouth (vomitus) –Metabolic Alkalosis
Potassium & Alkalosis – ALKALOSIS: K is LOW
– Acidosis is just the opposite: K is High
4
Arterial Blood Gases
1. Prior to drawing an ABG, perform the Allen’s Test to check for sufficient blood flow
2. When drawing an ABG, the blood needs to be put in a heparinized tube.
● Ensuring there are no bubbles.
3. Put on ice immediately after drawing, with a label.
● The label should indicate if the pt was on room air, or how many liters of O2.
General Notes
● The person who hyperventilates is most likely to experience respiratory alkalosis.
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 o
Continue to monitor o Document finding
• Unexpected finding with Disease Process o
Nursing intervention that must make a
difference o 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’re left with two answer choices and the options are to Tx, or watch the patient,
Pick Tx!
11. Anytime there’s a reversal from the norm, you must worry!
Ex: rebound tenderness (pain after you relieve pressure)
12. Stable Patients
∙ UAP ∙ LPN ∙ New nurse
∙ Graduate Nurse ∙ Float Nurse ∙ Travel nurse
13. Anytime you see excessive findings, That’s 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 patient
2) Reassure – Delirium
1
3) Redirect – Dementia
Default Answers
1. Give meds either 1 hour before meal or 2 hours after meal
2. Give antacids 1 hour before med or 4 hours after med
3. When in doubt pick K (potassium)
4. 2 – 3 L of fluids
5. When in doubt pick answer that has you stay with patient
6. Anytime you see restless & ↓ level of consciousness = early sign always pick
7. Head of Bead → 30-45 degrees for any neuro patient
, 1
3) Redirect – Dementia
Default Answers
1. Give meds either 1 hour before meal or 2 hours after meal
2. Give antacids 1 hour before med or 4 hours after med
3. When in doubt pick K (potassium)
4. 2 – 3 L of fluids
5. When in doubt pick answer that has you stay with patient
6. Anytime you see restless & ↓ level of consciousness = early sign always pick
7. Head of Bead → 30-45 degrees for any neuro patient
8. Elderly with acute onset confusion → UTI
9. Secretions will turn Orange/Red for meds
10. Anytime you have GI problem/exacerbation = NPO
11. All surgeries
1st 24 hrs – bleeding
48 hrs – infection
12. Check daily weights if it’s a fluid problem
13. Lateral position for maternity
14. Remove answer choices that are ‘absolutes’
Kaplan NCLEX Strategies
Kaplan RN Decision Tree
Step 1 – Can you identify the topic of the question
Step 2 – Are the answers assessment (get data) or implementation (to effect change)?
Step 3 – Apply Maslow: Are the answers physical or psychosocial? (Physical trumps psychosocial)
Step 4 – Are the answer choices related to ABCs?
Step 5 – What is the outcome of each of the remaining answers?
Rules for Delegation
RN ASSIGNMENT
● Cannot delegate assessment, teaching, or nursing judgement EAT, or planning 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:
2
● Do respond to feeling tone ● Do not ask ‘why’ questions
● Do provide information ● Do not ask ‘yes/no’ questions, except in the case of possible self-harm
● Do focus on the client ● Do not focus on the nurse
● Do use silence ● Do not explore
● Do use presence ● Do not say, “Don’t worry!”
Who Do You See First?
Consider:
,DO: DO NOT:
2
● Do respond to feeling tone ● Do not ask ‘why’ questions
● Do provide information ● Do not ask ‘yes/no’ questions, except in the case of possible self-harm
● Do focus on the client ● Do not focus on the nurse
● Do use silence ● Do not explore
● Do use presence ● 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 NCLEX 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 assignments to someone else
∙ Do not say, “Don’t worry!”
Strategies
● Only use textbook nursing – textbook knowledge
● Pain is psychosocial, unless, it’s severe, acute, & unrelenting
● If it’s a position question, is it going to prevent or promote something – position, prevent, promote
● Teaching/learning – use T/F on each answer
● 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
3
Important Lab Values
, 3
Important Lab Values
Therapeutic PTT: 1.5 – 2x the normal value (46 – 76 Seconds)
Cholesterol
HDL
LDL
Therapeutic Ranges
Dilantin Theophylline
Acetaminophen
Digoxin 2.0
Albumin level 3.5 to 5.5
Acid-Base Balance
From the ass (diarrhea) –Metabolic Acidosis
From the mouth (vomitus) –Metabolic Alkalosis
Potassium & Alkalosis – ALKALOSIS: K is LOW
– Acidosis is just the opposite: K is High
4
Arterial Blood Gases
1. Prior to drawing an ABG, perform the Allen’s Test to check for sufficient blood flow
2. When drawing an ABG, the blood needs to be put in a heparinized tube.
● Ensuring there are no bubbles.
3. Put on ice immediately after drawing, with a label.
● The label should indicate if the pt was on room air, or how many liters of O2.
General Notes
● The person who hyperventilates is most likely to experience respiratory alkalosis.
