Nclex Help

8/16/2019 Nclex Help

1/18

1HESI Hints and NCLEX Gems

• Answering NCLEX questions

o Maslow’s Hierarch o! Needs

"hsiologic

Sa!et

Lo#e and $elonging

Esteem

Sel!%Actuali&ation

o Nursing "rocess Assessment

'iagnosis

"lanning

Im(lementation

E#aluation

o A$Cs

Airwa

$reathing

Circulation

• Normal )alues

o Hg*

Males 1+ , 1- .emales 1/ , 10

o Hct

Males +/ , /

.emales 23 , +3

o 4$Cs

Males5 +63 , 061million

.emales5 +6/ , 6+ million

o 7$Cs

+6 , 118

o "latelets

19 , +998

o

": ;Coumadin


2/18

/o S(ecic Gra#it5 1699 , 16929

o Hg*A1C5

Ideal > +%0F

;1/9 das= @3F

o 'ilantin :45 19 , /9

o Lithium :45 96 , 16

o Arterial $lood Gas

(H > 362 , 36+

C/ > 2 , + HC2 > // , /-

/ > -9 , 199

/ Sat > D , 199F

• Antidotes

o 'igoin , 'igi*and

o Coumadin , )it 8

o $en&os , .lum&aemil ;:oma&icon=

o He(arin , "rotamine Sul!ate ;8ee( a":: and ":: at 16%/ times normal=

o :lenol , Mucomst ;loading dose 13 doses=

o (iates ;narcotics analgesicsB heroinB mor(hine= , Narcan ;naloone=

o Cholinergic meds ;mesthenic *radcardia= , Atro(ine

o Methotreate , Leuco#orin• 'elegation

o 4N onl

$lood (roducts ;/ 4Ns must chec=

Clotting !actors

Sterile dressing changes and (rocedures

Assessments that require clinical Judgment

?ltimatel res(onsi*le !or all delegated duties

o ?nlicensed Assisti#e "ersonnel

Non%sterile (rocedures

• "recautions and 4oom Assignments

o ?ni#ersal ;Standard= "recautions , HI) initiated

7ash hands

7ear glo#es

Gowns !or s(lashes

Mass and Ee (rotection !or s(lashes and dro(lets

'on’t reca( needles

Mouth(iece o! Am*u%*ag !or resuscitation

4e!rain !rom gi#ing care i! ou ha#e sin lesions

o 'ro(let ;4es(irator= "recautions , wear mas

Se(sisB scarlet !e#erB stre(B !th disease ;"ar#o $1D=B (ertusisB (neumoniaB

inKuen&aB di(htheriaB e(iglottitisB ru*ellaB ru*eolaB meningitisB mco(lasmaB

adeno#irusB rhino#irus 4S) ;needs contact (recautions too=

:$ ;4es(irator isolation=

o Contact "recautions > uni#ersal gogglesB masB and gowno No in!ectious (atients with immunosu((ressed (atients

Clean with clean

'irt with dirt

• Misc6

o 4i!am(in ;!or :$= , rust


3/18

2o 'ia*etic Coma #s6 Insulin Shoc Gi#e glucose rst , I! no hel(B gi#e insulin

o .ruit $reath > 'ia*etic 8etoacidosis

o Acid%$ase $alance

I! it comes out o! our assB it’s Acidosis6

)omiting > Alalosis

o Sin :astes Salt > Cstic .i*rosis

o Li(itor ;statins= in "Ms onl , No gra(e!ruit Juice

o Stroe

:ongue (oints toward side o! lesion ;(aralsis= ?#ula de#iates awa !rom the side o! lesion ;(aralsis=

o Hold 'igoin i! H4 @ 09

o Sta in *ed !or 2 hours a!ter rst ACE Inhi*itor dose

o A#oid Gra(e!ruit Juice with CC$s

o Anthra > Multi%#ector *ioha&ard

o "ulmonar air em*olism (re#ention > :rendelen*erg ;H$ down= on le!t side ;to tra( air

in right side o! heart=o Head :rauma and Sei&ures , maintain airwa > (rimar concern

o "e(tic ?lcers

.eed a 'uodenal ?lcer ;(ain relie#ed * !ood=

Star#e a gastric ulcer

o Acute "ancreatitis .etal (ositionB $luish discoloration o! Kans ;:urner’s Sign=B $luish discoloration o!

(ericum*elical region ;Cullen’s Sign=B $oard lie a*domen with guarding Sel! digestion o! (ancreas * tr(sin6

o Hold tu*e !eeding i! residual 199mL

o In case o! .ire , 4ACE and "ASS

o Chec 4estraints e#er 29 minutes , / ngers room underneath

o Gullian%$arre Sndrome

7eaness (rogresses !rom legs u(ward , leads to 4es( arrest

o :rough draw > 29 min *e!ore scheduled administration

o "ea 'raw > 29%09 min a!ter drug administration6

• Mental Health and "schiatr

o Most suicides occur a!ter *eginning o! im(ro#ement with increase in energ le#els

o MAIs

H(ertensi#e Crisis with :ramine !oods

NardilB Mar(lanB "arnate

Need / w ga( !rom SS4Is and :CAs to admin MAIs

o Lithium :hera(eutic 4ange > 96%16

o "henothia&ines ;t(ical anti(schotics= , E"SB "hotosensiti#it

o At(ical Anti(schotics , wor on (ositi#e and negati#e sm(tomsB less E"S

o $en&os ;Ati#anB Lora&e(amB etc= good !or Alcohol withdrawal and Status E(ile(ticus

o Anta*use !or Alcohol deterrence , Maes ou sic with H intae

o Alcohol 7ithdrawal > 'elirium :remens , :achcardiaB tach(neaB anietB nauseaB

shaesB hallucinationsB (aranoia ;':s start 1/%20 hrs a!ter last drin=o (iate ;HeroinB Mor(hineB etc6= 7ithdrawal > 7ater eesB runn noseB dilated (u(ilsB

N)'B cram(so Stimulants 7ithdrawal > 'e(ressionB !atigueB anietB distur*ed slee(

• Medical%Surgical

o H(o#entilation > Acidosis ;too much C/=

o H(er#entilation > Alalosis ;low C/=

o No $" or I) on side o! Mastectom

o (iate ' > "in(oint "u(ils

o Lesions o! Mid*rain > 'ecere*rate "osturing ;Etended el*owsB head arched *ac=

o Lesions o! Corte > 'ecorticate "osturing ;.leion o! el*owsB wristsB ngersB straight legsB

mumm (osition=o ?rine ut(ut o! 29 mL minimal com(etenc o! heart and idne !unction


4/18

+o 8idne Stone > Cholelithiasis

.lan (ain > stone in idne or u((er ureter

O A*dominal stone in mid Inter!erence with renal (er!usion

Intra%renal "ro*lem> 'amage to renal (arenchma

"ost%renal "ro*lem > *struction in ?: anwhere !rom tu*ules to urethral meatus6 ?suall 2 (hases ;ligouricB 'iureticB 4eco#er=

Monitor $od 7t and IPs

o Steroid EQects > Moon !aceB h(erglcemiaB acneB hirsutismB *uQalo hum(B mood swingsB

weight gain S(indle sha(eB osteo(orosisB adrenal su((ression ;delaed growth in ids=

;Cushing’s Sndrome sm(toms=o Addison’s’ Crisis > medical emergenc ;#ascular colla(seB h(oglcemiaB tachcardia

Admin I) glucose corticosteroids=

No " corticosteroids on em(t stomach

o "otassium s(aring diuretic > Aldactone ;S(ironalactone=

7atch !or h(er8 with this and ACE Inhi*itors6

o Cardiac En&mes :ro(onin ;1 hr=B C8M$ ;/%+ hr=B Moglo*in ;1%+ hr=B L'H1 ;1/%/+ hr=

o MI :

Nitro , Res

N 'igoinB $eta *locersB Atro(ine

o .i*rinoltics > Stre(toinaseB :enecte(lase ;:N8ase=

o CA$G > Coronar Arter $(ass Gra!t

o ":CA > "ercutaneous :ransluminal Coronar Angio(last

o Se a!ter MI oa when a*le to clim* / Kights o! stairs without eertion

:ae nitro (ro(hlacticall *e!ore se

o $"H : > :?4" ;:ransurethral 4esection o! "rostate=

Some *lood !or + dasB and *urning !or 3 das (ost%:?4"6

o nl isotonic sterile saline !or $ladder Irrigation

o "ost :hroidectom , 8ee( tracheostom set * the *ed with /B suction and Calcium

gluconateo "ericarditis

"ericardial .riction 4u*B "ain relie#ed * leaning !orward

o "ost Stre( ?4I 'iseases and Conditions5

Acute Glomerulone(hritis

4heumatic .e#er , )al#e 'isease

Scarlet .e#er

o I! a chest%tu*e *ecomes disconnectedB do not clam( , "ut end in sterile water

o Chest :u*e drainage sstem should show *u**ling and water le#el Kuctuations ;tidaling

with *reathing=o :$

:reatment with multidrug regimen !or D months

4i!am(in reduces eQecti#eness o! Cs and turns urine orange

Isonia&ide ;INH= increases 'ilantin *lood le#els

o ?se *ronchodilators *e!ore steroids !or asthma

Ehale com(letelB Inhale dee(lB Hold *reath !or 19 seconds

o )entilators

Mae sure alarms are on

Chec e#er + hours minimum

o Suctioning

"re and "ost ogenate with 199F /


5/18

No more than 2 (asses

No longer than 1 seconds

Suction on withdrawal with rotation

o C"'5

Em(hsema > "in "uQer

Chronic $ronchitis > $lue $loater ;CanosisB 4ight sided heart !ailure >

*loating Earl signs o! cere*ral h(oia

• I)s and $lood "roduct Administration

o 1-%1D gauge needle !or *lood with lter in tu*ing

o 4un *lood with NS onl and within 29 minutes o! hanging

o )itals and $reath Sounds

$e!oreB during and a!ter in!usion ;1 min a!ter startB then 29 min laterB then hourl

u( to 1 hr a!ter=

o Chec $lood5 E( 'ateB clotsB colorB air *u**lesB leaso / 4Ns must chec orderB (tB *lood (roduct , As "t a*out (re#ious trans!usion H

o Sta with "t !or rst 1 minutes , I! trans!usion reaction , Sto( and 8) with NS

o "re%medicate with $enadrl "4N !or (re#ious urticaria reactions

o Isotonic Solutions

'7

NS ;96DF NaCl=

4ingers Lactate

NS onl with *lood (roducts and 'ilantin

• 'ia*etes and Insulin

o 7hen in dou*t , :reat !or H(oglcemia rst

o

.irst I) !or '8A > NSB then in!use regular insulin I) as 4’do H(oglcemia con!usionB HAB irrita*leB nauseaB sweatingB tremorsB hungerB slurring

o H(erglcemia weanessB snco(eB (oldi(siaB (oluriaB *lurred #isionB !ruit *reath

o Insulin ma *e e(t at room : !or /- das

o 'raw 4egular ;Clear= insulin into sringe rst when miing insulins

o 4otate InJection Sites ;4otate in 1 regionB then mo#e to new region=

o 4a(id Acting Insulins

Lis(ro ;Humalog= and As(art ;No#olog=

5 %1 minB "5 63%16 hrs

o Short Acting Insulin

4egular ;human=

5 29%09 minB "5 /%2 hrs ;I) a=

o Intermediate Acting Insulin

Iso(hane Insulin ;N"H= 5 1%/ hrsB "5 0%1/ hrs

o Long Acting Insulin

Insulin Glargine ;Lantus=

5 161 hrB "5 1+%/9 hrs ;'on’t Mi=

o ral H(oglcemics decrease glucose le#els * stimulating insulin (roduction * *eta cells

o! (ancreasB increasing insulin sensiti#it and decreasing he(atic glucose (roduction Gl*urideB Met!ormin ;Gluco(hage=B A#andiaB Actos

Acar*ose *lunts sugar le#els a!ter meals

• ncolog

o Leuemia


6/18

0 Anemia ;reduced 4$C (roduction=

Immunosu((ression ;neutro(enia and immature 7$Cs=

Hemorrhage and *leeding tendencies ;throm*octo(enia=

Acute Lm(hoctic , most common t(eB (edsB *est (rognosis

o :esticular Cancer

"ainless lum( or swelling in testicles

S:E in shower 1+ 6o6

Common ages , 1%2 6o6

o "rostate Cancer Age % +9 6o6

"SA ele#ation

'4E

Metastasis to s(ineB hi(sB and legs

Ele#ated "A" ;"rostate Acid "hos(hatase=

:4?S % :ransurethral ?S

"ost ( , monitor o! hemorrhage and cardio#ascular com(lication

o Cer#ical and ?terine Cancer

LaserB crothera(B radiationB coni&ationB hsterectomB eoneration

Chemothera( > no hel(

"a( smears should start within 2 rs o! intercourse o! * age /1

o #arian Cancer Leasing cause o! death !rom gnecological cancers

o $reast Cancer

Leading cause o! cancer in women

?((er outer quadrantB le!t right

Monthl S$E

Mammogra(h , *aseline at 2 6o6B annuall at 9 6o6

Metastasis to lm(h nodesB then lungsB li#erB *rainB s(ine

Mastectom , radical mastectom > lm(h nodes too ;*ut no mm resected=

A#oid $" measurementsB inJectionsB and #eni(uncture on surgical side

o Anti%emetics gi#en with Chemothera( Agents ;CtoanB MethotreateB Inter!eronB etc6=

"henergan ;"rometha&ine HCl=

Com(a&ine ;"rochlor(era&ine=

4eglan ;Metoclo(ramide=

$enadrl ;'i(henhdramine=

o!ran ;ndansetron HCl=

8tril ;Granisetron=

• Seuall :ransmitted 'iseases

o S(hilis ;:re(onema (allidum=

"rimar Stage ;D9 das= > Chancre red (ainless lesion

Secondar Stage ;u( to 0 mo= > 4ash on (alms and soles .lu%lie sm(toms

:ertiar Stage ;19%29 rs= > Neurologic and Cardiac destruction

:reated with "enicillin G IM

o Gonorrhea ;Neisseria Gonorrhea=

Rellow green urethral discharge ;:he Cla(=

o Chlamdia ;Chlamdia :rachomatis= Mild #aginal discharge or urethritis

'occlinB :etraccline

o :richomoniasis ;:richomonas )aginalis=

.roth !oul%smelling #aginal discharge

.lagl

o Candidiasis ;Candida Al*icans=

RellowB chees discharge with itching

Icona&oleB NstatinB Clomitra&ole ;Gne%Lotrimin=

o Her(es Sim(le /

Acclo#ir


7/18

3o H") ;Human "a(ilo#irus=

AcidB LaserB Crothera(

o HI)

Coctails

• "erio(erati#e Care

o $reathing Es taught in ad#ance ;*e!ore or earl in (re%o(=

o 4emo#e nail (olish ;need to see ca( rell=

o "re (

Meds as orderedB N" X - hrsB Incenti#e S(irometr P $reathing is taught inad#anceB )oidB No NSAI'S X +- hrs

o Increased corticosteroids !or surger ;stress=

Ma need to increase insulin too

o "ost ( restlessness ma mean hemorrhageB h(oia

o 7ound dehiscence or etra#isation

7et sterile NS dressingB Call 'r6

o Call 'r6 (ost o( i! @ 29 mL Immediate Stage

o /%/+ hrs "ost ( > Intermediate Stage

o 1%+ das "ost ( > Etended Stage

o :otal Hi( 4e(lacement , No adduction (ast midlineB no hi( Keion (ast D9 degrees

o Su(ratentorial S , H$ 29%+ degrees ;semi%!owlers=

o In!rantentorial S , .lat

o "hle*itis , Su(ineB ele#ate in#ol#ed leg

o Harris :u*e , rightB *acB le!t , to ad#ance tu*e in GI

o Miller A**ott :u*e , 4ight side !or GI ad#ancement into small intestine

o :horacentesis , unaQected sideB H$ 29%+ degrees

o Enema , Le!t Sims ;Kows into sigmoid=

o Li#er $io(s , 4ight side with (illow


8/18

- Sudden res(irator distress , Cut inKation tu*es and remo#e

o :rach (atients

8ee( 8ell clam( and o*turator Dused to insert into trachea then remo#ed lea#ing

cannula= at *edsideo :urn oQ NG suction !or 29 minutes a!ter " meds

o NG :u*e remo#al

:ae a dee( *reath and hold it

o Stomach contents (H > @+ ;gastric Juices as(irated=

o NG :u*e insertion I! cough and gag , *ac oQ a littleB let (t calm downB ad#ance again with (t si((ing

water !rom straw

o NG :u*e length

End o! nose to ear lo*e to (hoid (rocess ;a*out //%/0 inches=

o 'ecu*itus ;"ressure= ?lcer Staging

Stage 1 , Erthema onl

Stage / , (artial thicness

Stage 2 , !ull thicness to S

Stage + , !ull thicness and in#ol#ing muscle or *one

• Acute Care

o C)A , Hemorrhagic or Em*olic A%* and A%Kutter > throm*us !ormation

'sarthria , #er*al enunciation common cause o! death ;tr to ee( urine acidic=

o $urns

In!ection > (rimar concern

H(er8 due to cell damage and release o! intracellular 8

Gi#e meds *e!ore dressing changes , (ain!ul

Massi#e #olumes o! I) Kuid gi#en due to Kuid shi!t to interstitial s(aces and

resultant shoc .irst 'egree > e(idermis ;su(ercial (artial thicness=

Second 'egree > E(idermis and 'ermis ;dee( (artial thicness=


9/18

D :hird 'egree > E(idermisB 'ermisB and S ;!ull thicness=

4ule o! Ds

• Head and Nec , DF ;+6F each side=

• ?((er etremities , DF each

• Lower etremities , 1-F each

• .ront trun , 1-F

• $ac trun , 1-F

Singed nasal hairs and circumoral soot smoe inhalation *urns

o .ractures

4e(ort a*normal assessment nding (rom(tl

Com(artment Sndrome ma occur > (ermanent damage to ner#es and #essels

"s o! neuro#ascular status ;im(ortant with !ractures=

• "ainB "allorB "ulseB "aresthesiaB "aralsis

"ro#ide age%a((ro(riate tos !or children in traction

• S(ecial :ests and "athognomonic Signs

o :ensilon :est > Masthenia Gra#is ;(os > Masthenia crisisB neg > cholinergic crisis=

o ELISA and 7estern $lot > HI)

o Sweat :est > Cstic .i*rosis

o Cheilosis > sores on sides o! mouth > 4i*oKa#in decienc ;$/=

o :rousseau’s Sign ;car(al s(asm induced * $" cuQ= > H(ocalcemia H(ocalcemia ulcerati#e colitis

o li#e%sha(ed mass in e(igastric region and (roJectile #omiting > "loric Stenosis

o Current Jell stool ;*lood and mucus= and sausage%sha(ed mass in 4? > Intussusce(tion

o Mantou :est !or :$ is (ositi#e i! 19mm induration +-hr (ost admin

mm induration is (ositi#e !or immunocom(romised (ts

"re#ious $CG #accine reci(ients will test (ositi#e

o $utterK 4ash > SLE ;a#oid direct sunlight=

o "s o! N) !unctioning "ainB (aresthesiaB (ulseB (allorB (aralsis

o Cullen’s sign ;(erium*elical discoloration= and :urner’s sign ;*lue Kan= > Acute

"ancreatitis

o Mur(h’s sign ;right costal margin (ain on (al(ation with ins(iration= > G$ or Li#erdisease

o Headache more se#ere on waening > $rain :umor ;remo#e *enign and malignant=

o )omiting nor associated with nausea > $rain :umor

o Ele#ated IC" > increased $"B widened (ulse (ressureB increased tem(

o "ill%4olling :remor > "arinson’s ;: with Le#odo(aB Car*ido(a=

.all (recautions

4igidB stoo(edB shuTing

o IG $ands on Electro(horesis > MS

7eaness starts in u((er etremities

$owel


10/18

19 Anterior !ontanel closes * 1/%1- months

Moro reKe disa((ears at + months

Stead head control achie#ed at + months

:urns o#er at %0 months

Hand to hand trans!ers at 3 months

Sit unsu((orted at - months

Crawls at 19 months

7als at 19%1/ months

Cooing at / months Monoslla*ic *a**ling at 2%0 months

Lins slla*les at 0%D months

MamaB 'ada (lus a !ew words at D%1/ months

:hrows a *all o#erhand at 1- months

'atime toilet training at 1-%/+ months

/%2 word sentences at /+ months

9F o! adult ht at /+ months

$irth length dou*les at + rs

?ses scissors at + rs

:ies shoes at rs

Girls’ growth s(urt as earl as 19 6o6

$os catch u( around 1+ 6o6 .inish growing , girls around 1 ;/rs a!ter menstruation *egins=B *os around 13

o Autosomal 4ecessi#e 'iseases

C.B "8?B Sicle Cell AnemiaB :a%SachsB Al*inism

/F chance i!5 AS ;trait onl= AS ;trait onl=

9F chance i!5 AS ;trait onl= SS ;disease=

o Autosomal 'ominant 'iseases

Huntington’sB Mar!ansB "oldactl Achrondro(lasiaB "olcstic 8idne 'isease

9F i! one (arent has the disease disease in autosomal dominant=

o X%Lined 4ecessi#e 'iseases

Muscular 'stro(hB Hemo(hilia A

.emales are carriers ;rarel ha#e the disease=

9F chance sons will ha#e the disease ;not carrier > can’t (ass it on=

:his translates to an o#erall /F chance that each (regnanc will result in a child

that has the diseaseo Scoliosis

Milwauee *race , /2 hrs


11/18

11 In!ants with increased IC" , *ulging !ontanelsB high (itched crB increased head

circumB sunset eesB wide suture linesB letharg

• :reat with (eritoneal shunt , don’t (um( shunt

lder children with increased IC" , widened (ulse (ressure

Increased IC" cause * suctioningB coughingB strainingB and turning , tr to a#oid

o Muscular 'stro(h

X%lined 4ecessi#e

7addling gaitB h(er lordosisB Gower’s signB Minor’s signB !at (seudoh(ertro(h o!

cal#eso Sei&ures

Nothing in mouthB turn head to sideB maintain airwaB don’t restrainB ee( sa!e

:reat with "heno*ar*ital ;Luminal=B (hentoin ;'ilantin5 :4>19%/9U gingi#al

h(er(lasia=B !os(hentoin ;Cere*=B #al(roic acid ;'e(aene=B car*ama&e(ine

;:egretol=o Meningitis ;*acterial=

Lum*ar (uncture shows increased 7$CsB (roteinB increased IC"B and decreased

glucose Ma lead to SIA'H , water retentionB Kuid o#erloadB dilutional h(onatremia

o C.

:aste salt

Need en&mes s(rinled on their !oodo Children with 4u*ella

:hreat to un*orn si*lings

Ma require tem(orar isolation !rom mom during (regnanc

o "ain in children is measured with the .ACES scale

o No MM4 immuni&ations !or children with H o! allergic reaction to eggs or neomcin

o Immuni&ation Side EQects

: @ 19/

4edness and soreness at inJection site !or 2 das

Gi#e :lenol and *ie (edal legs ;(assi#el= !or child

Call (hsician i! sei&ureB high !e#erB or high%(itched cr a!ter immuni&ations

o "oisonings

CALL "ISIN CN:4L N I"ECAC

o E(iglottitis > H6 InKuen&a $

Child sits u(right with chin out and tongue (rotruding ;ma*e tri(od (osition=

"re(are !or intu*ation or trache

' N: (ut anthing into the child’s mouth

o Isolate 4S) (atient with Contact "recautions

"ri#ate room is *est

?se Mist :ent to (ro#ide / and 4i*a#irin , Kood tent with / rst and wi(e down

inside o! tent (eriodicall so ou can see the (atiento Acute Glomerulone(hritis

?suall a!ter Stre(

Antigen%anti*od com(lees clog u( in glomeruli and reduce G.4

'ar urineB (roteinuria

o 7ilm’s :umor

Large idne tumor

' N: "AL"A:E

o :E. > :racheoeso(hageal Atresia

2 Cs o! :E. > CoughB choingB canosis

o Cle!t Li( and "alate

"ost ( , (lace on sideB maintain Logan $owB el*ow restraints

o Congenital Megacolon > Hirschs(rung’s 'isease

Lac o! (eristalsis due to a*sence o! ganglionic cells in colon


12/18

1/ Sus(ect i! no meconium within /+ hours or ri**on%lieB !oul smelling stools

o Iron 'ecienc Anemia

Gi#e iron on EM":R stomach with citrus Juice ;#itamin C enhances a*sor(tion=

?se straw or dro((er to a#oid staining teeth

:arr stools

Limit mil intae to @2/ o&


13/18

12o Conce(tion

'a 1 o! ccle > rst da o! menses ;*leeding=

#ulation on 'a 1+

:otal ccle das , /- das

S(erm , 2% dasU Eggs , /+ hrs

.ertili&ation in .allo(ian :u*e

o Signs o! "regnanc

Chadwic’s Sign > $luing o! #agina ;earl as + wees=

Hegar’s sign > So!tening o! isthmus o! cer#i ;- wees= Goodell’s Sign > so!tening o! the cer#i

o "regnanc Nutrition

"regnanc total wt gain > /%29 l*s ;11%1+ g=

Increased calorie intae * 299 calories 1/9%109

o .olic Acid 'ecienc > Neural :u*e 'e!ects

o :"AL> :ermB "re%term *irthsB A*ortions ;s(ontaneous and induced=B Li#ing Children

"re%term > /9%23 wees

:erm > 2-%+/ wees

"ost%term > V+/ wees

o Gra#ida > num*er o! (regnanciesB regardless o! outcome

o "ara > num*er o! deli#eries ;not children= a!ter /9 wees gestation

o Nagale’s 4ule , Add 3 das to rst da o! last (eriodB su*tract 2 monthsB add 1/ months >

E'Co Hg* and Hct are slightl lower during (regnanc due to h(erhdration

o Side%ling is *est (osition !or utero(lacental (er!usion ;either sideB *ut LE.: side is more

traditional=o /51 Lecithin5S(hingomelin 4atio > !etal lungs are mature

o A." in amniotic Kuid > (ossi*le neural tu*e de!ect

o Need a !ull *ladder !or amniocentesis earl in (regnanc ;*ut not later in (regnanc=

o Lightening > !etus dro(s into true (el#is

o Nesting instinct > *urst o! energ Just *e!ore la*or

o :rue la*or > regular contractions that intensi! with am*ulationB L$" that radiates to

a*domenB (rogressi#e dilation and eQacemento Station > negati#e a*o#e Ischial s(inesB (ositi#e *elowo Leo(old Maneu#er tried to re(osition !etus !or deli#er

o La*oring maternal #itals , (ulse @199 ;usuall a little higher than normal with (regnanc=B

$" is unchangedB tem( @1996+o Non%stress test , reacti#e > health ;.H4 goes u( with mo#ements=

o Contraction Stress :est ;tocin Challenge :est=

"ositi#e > late decels noted > unhealth

• Indicati#e o! ?"I

Negati#e > no late decels noted > health

o "re%Eclam(sia > H:N Edema "roteinuria

o Eclam(sia > H:N Edema "roteinuria Sei&ures and Coma


14/18

1+ Sus(ect i! se#ere HA #isual distur*ances

o Magnesium sul!ate used to reduce (reterm la*or contractions and (re#ent sei&ures in "re%

Eclam(sia Mg re(laces Ca in the smooth muscle cells resulting in relaation

Can lead to h(oreKeia and res(irator de(ression ;dia(hragmatic inhi*ition=

• Must ee( calcium gluconate ;antidote= * *ed when administering during

la*or Monitor !or5

• A*sent ':4’s

• 4es(irations @1/

• ?rinar out(ut @29cc le#el o! um*ilicus

4ises a*out 1cm *eginning o! regular contraction to !ull dilation and eQacement

Stage / > 19cm dilation to deli#er

Stage 2 > deli#er o! (lacenta

Stage + > 1%+ hrs !ollowing deli#er

o Anesthetic $locs

"udendal *loc > decreases (ain in (erineum and #agina , no hel( with

contraction (ain E(idural *loc > :19%S

•

$locs all (ain• .irst sign > warmth or tingling in *all o! !oot or *ig toe

4egional *locs o!ten result in !orce(s or #acuum assisted *irths *ecause the

aQect the mother’s a*ilit to (ush eQecti#elo :ears

1st degree , 'ermis

/nd degree , mm

2rd degree , anal s(hincter

+th degree , rectum

o "lacenta

A*ru(tio "lacenta > dar red *leeding with rigidB *oard%lie a*domen


15/18

1 "lacenta "re#ia > (ainless *right red *leeding

"lacenta Se(aration

• Lengthening o! cord outside o! #aginaB gush o! *loodB !ull !eeling in #agina

• Gi#e otocin a!ter (lacenta is out , N: $E.4E

Schult& "resentation > shin side outside ;!etal side o! (lacenta=

• "ost(artum

o "ost(artum )S Schedule

E#er 1 min !or 1 hr

E#er 29 min !or net / hrs E#er hour !or the net /%0 hrs

:hen e#er + hrs

o $M !or mom within 2 das > normal

o Lochia

No more than +%- (ads in!ection

o Massage *ogg uterus to encourage in#olution , em(t *ladder ASA"

Ma need to catheteri&e

.ull *ladder can lead to uterine aton and hemorrhage

o 'IC , : with He(arin ;sa!e in (regnanc= , !etal demiseB a*ru(tio (lacentaB in!ection

o 7$C counts are ele#ated u( to /B999 !or a*out 19 das (ost%(artumo C%section can lead to (araltic ileus , earl am*ulation hel(s

o "ost(artum in!ection common in (ro*lem (regnancies , anemiaB 'MB traumatic *irth

o "ost(artum Hemorrhage > leading cause o! maternal death6

4is !actors include5 dstociaB (rolonged la*orB o#erdistended uterusB a*ru(tio

(lacentaB in!ection : includes5 !undal massageB count (adsB )SB I) KuidsB otocinB noti! (hsician

• New*orn

o $a*ies *orn without #aginal squee&e more liel to ha#e res(irator diWcult initiall

o A"GA4 > H4B 44B mm toneB reKect irrita*ilitB color

1 and minutes

3%19 > GoodU +%0 > moderate resuscitati#e eQortsU 1%2 mostl dead

o

Ee care > E%mcin Sil#er nitrate , !or gonorrheao 4ho;'= immune glo*ulin ;4hoGAM= is gi#en to 4h% mothers who deli#er 4h children

Not gi#en is mom has a (ositi#e Coom*s test , she alread has de#elo(ed

anti*odies6 :oo lateo Ca(ut Succedaneum > edema under scal( , crosses suture line

o Ce(halhematoma > *lood under (eriosteum , does not cross suture lines

o Suction mouth .I4S:B then nostrils

o Moro 4eKe > startle reKe , a*duction o! all etremities ;u( to + months=

o 4ooting reKe , u( to + months

o $a*insi reKe , u( to 1- months

o "almar Gras( reKe , lessens * + months

o $allard Scale used to estimate gestational age

o Heel Stic , lateral sur!ace o! heel

o "hsiologic Yaundice is normal at /%2 das A*normal is *e!ore /+ hrs or lasting longer than 3 das

?nconJugated *iliru*in is the cul(rit

o )it 8 is gi#en to hel( with !ormation o! clotting !actors due to the !act that the new*orn

gu lacs the *acteria necessar !or )it 8 snthesis initiall Gi#en in the #astus lateralis mm IM

o 'IC , clotting !actors used u( * intra#ascular clotting

Hemorrhage and increased *leeding times result

Associated with !etal demiseB in!ectionB and a*ru(tion (lacenta

o H(othermia can lead to h(oia and acidosis

8ee( warm and use *icar* "4N to treat acidosis in new*orn


16/18

10o La *a* on right side a!ter !eeding , hel(s mo#e stomach contents into small intestine

o Yaundice and high *iliru*in can cause ence(halo(ath

@1/ > normal

"hotothera( decom(oses *iliru*in #ia oidation

"rotect eesB turn e#er / hrs and watch !or dehdration

:he dangerous *iliru*in is the unconJugated indirect t(e

o Yitteriness is a sm(tom o! h(oglcemia and h(oglcemia in the new*orn

H(oglcemia , tremorsB high%(itched crB sei&ures

o Increased IC" > high%(itched cr *ulging !ontanels• Nutrition

o 8 % *ananasB dried !ruitsB citrusB (otatoesB legumesB teaB (eanut *utter

o )it C , citrusB (otatoesB cantalou(e

o Calcium , milB cheeseB green lea! #eggiesB legumes

o Sodium , saltB (rocessed !oodsB sea!ood

o .olic Acid , green lea! #eggiesB li#erB citrus

o Iron , Green lea! #eggiesB red meatB organ meatB eggsB whole wheatB carrots

?se %tract !or inJections to a#oid sin staining

o Magnesium , whole grainsB green lea! #eggiesB nuts

o :hiamine ;$1= , (orB *ee!B li#erB whole grains

o $1/ , organ meatsB green lea! #eggiesB eastB milB cheeseB shellsh

'ecienc > *ig *ee! red tongueB anemiao )it 8 , GreenB lea! #eggiesB milB meatB so

o )it A , Li#erB orange and dar green !ruits and #eggies

o )it ' , dairB sh oilB sunlight

o )it E , #eggie oilsB a#ocadoesB nutsB seeds

o $MI , 1-6%/+6D > normal ;higher > o#erweight or o*ese=

• Gerontolog

o Essentiall e#erone does to Hell in a (rogressi#el degenerati#e hand%*aset

o :hin sinB *ad slee(B muscle wastingB memor lossB *ladder shrinsB incontinenceB delaed

gastric em(tingB C"'B h(othroidismB dia*eteso Common Ailments

'elirium and dementia

Cardiac dsrhthmias

Cataracts and glaucoma

C)A ;usuall throm*olticB :IAs common=

'ecu*itus ulcers

H(othroidism

C" ;usuall a com*o o! em(hsema and C$=

?:Is and "neumonia , can cause con!usion and delirium

Memor loss starts with recent , (rogresses to !ull

'ementia > irre#ersi*le ;Al&heimer’s= , de(ressionB SundowningB loss o! !amil

recognition Medication Alert , 'ue to decreased renal !unctionB drugs meta*oli&ed * the

idnes ma (ersist to toic le#els 7hen in dou*t on NCLEX , answer should contain something a*out eercise and

nutritiono Ad#anced Clinical Conce(ts

Ericson , "schosocial 'e#elo(ment

• 9%1 r ;New*orn= , :rust #s6 Mistrust

• 1 , 2 ears ;:oddler= , Autonom #s6 'ou*t and Shame

o .ear intrusi#e (rocedures

o Securit o*Jects are good ;*lanetB stuQed animal=

• 2 , 0 ears ;"re%school= , Initiati#e #s6 Guilt

o .ear mutilation

o $and%Aids are good

• 0 , 1/ ears ;School Age= , Industr #s6 In!eriorit


17/18

13o Games are good

o "eers are im(ortant

o .ear o! loss o! control o! their *odies

• 1/ , 1D ears ;Adolescent= , Identit #s6 4ole con!usion

o .ear *od image distortion

• /9 , 2 ears ;Earl Adulthood= , Intimac #s6 Isolation

• 2 , 0 ears ;Middle Adulthood= , Generati#it #s6 Stagnation

• #er 0 ;lder Adulthood= , Integrit #s6 'es(air

"iaget , Cogniti#e 'e#elo(ment

• Sensorimotor Stage ;9%/ 6o6= , Learns a*out realit and o*Ject

(ermanence

• "reo(erational Stage ;/%3 6o6= , Concrete thining

• Concrete (erational Stage ;3%11 6o6= , A*stract :hining

• .ormal (erational Stage ;11%adult= , A*stract and Logical :hining

.reud , "scho%seual 'e#elo(ment

• ral Stage ;*irth to 1 ear= , sel! graticationB Id is in control and running

wild

• Anal Stage ;1%2= , control and (leasure wrt retention and (oo(ing , toilet

training in this stage

• "hallic Stage ;2%0= , (leasure with genitalsB edi(us com(leB Su(erEgo

de#elo(s

• Latenc Stage ;0%1/= , se urges channeled to culturall acce(ta*le le#elB

growth o! Ego

• Genital Stage ;1/ and u(= , gratication and satis!ing seual relationsB

Ego rules 8ohl*erg , Moral 'e#elo(ment

• Moral de#elo(ment is sequentialB *ut (eo(le do not aromaticall go !rom

one stage to the net as the mature

• Le#el 1 > "recon#entional , 4eward #s6 "unishment orientation

• Le#el / > Con#entional Moralit , con!orms to rules to (lease others

• Le#el 2 > "ost%con#entional , rightB (rinci(lesB and conscience ;$est .or

All is a concern=• Calculations 4ules and .ormulas

o 4ound nal answer to tenths (lace

o 4ound dro(s to nearest dro(

o 7hen calculating mL


18/18

1-o 2- C > 1996+ .

o 2D C > 19/6/ .

o +9 C > 19+

• .all "recautions

o 4oom closes to nurses station

o Assessment and orientation to room

o Get hel( to stand ;dangle !eet i! lightheaded=

o $ed low with side rails u(

o Good lighting and reduce clutter in roomo 8ee( consistent toileting schedule

o 7ear (rotecti#e non%sli( !ootwear

o At home

"aint edges o! stairs *right color

$ell on cats and dogs

• Neutro(enic ;Immunosu((ressed= "recautions

o No (lants or Kowers in room

o No !resh !ruits or #eggies

o .ull cooed !oods onl

o A#oid crows and in!ectious (ersons

o Meticulous hand%washing and hgiene to (re#ent in!ection

o 4e(ort !e#er 1996 ;immunosu((ressed (ts ma not mani!est !e#er with in!ection=• $leeding "recautions

o So!t%*ristled tooth*rush

o Electric ra&ors onl

o Handle gentl

o Limit contact s(orts

o Limit needle sticsB use small *ore needlesB maintain (ressure !or min on #eni(uncture

siteso No straining , chec stools !or occult *lood ;stool so!teners "4N=

o No saliclatesB NSAI'sB or su((ositories

o A#oid *lowing or (icing nose

o 'o not change )it 8 intae i! on Coumadin

Nclex Help

Documents

Transcript of Nclex Help