Hesi Hints And Nclex Gems-Nclex Revıew Sheets

 Hesi Hints And Nclex Gems-Nclex Revıew Sheets

HESI Hints and NCLEX Gems

 Answering NCLEX questions

o Maslow’s Hierarchy of Needs

 Physiologic

 Safety

 Love and Belonging

 Esteem

 Self-Actualization

o Nursing Process

 Assessment

 Diagnosis

 Planning

 Implementation

 Evaluation

o ABCs

 Airway

 Breathing

 Circulation

 Normal Values

o Hgb

 Males 14 – 18

 Females 12 – 16

o Hct

 Males 42 – 52

 Females 37 – 47

o RBCs

 Males: 4.7 – 6.1million

 Females: 4.2 – 5.4 million

o WBCs

 4.5 – 11K

o Platelets

 150 – 400K

o PT (Coumadin/Warfarin)

 11 – 12.5 sec

 INR and PT TR = 1.5-2 times normal)

o aPTT (Heparin)

 60 – 70 sec

o BUN: 10 – 20

o Creatinine: 0.5 – 1.2

o Glucose: 70 – 110

o Cholesterol: <200>

o Bilirubin newborn: 1 – 12

o Phenylalanine

 Newborn: <2>

 Adult: <6>

o Na: 135 – 145

o K: 3.5 – 5.0

 Hypokalemia: Prominent U waves, Depresses ST segment, Flat T waves

 Hyperkalemia: Tented T waves, prolonged PR interval, wide QRS

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o Calcium: 9 – 10.5

 Hypocalcemia: muscle spasms, convulsions, cramping, tetany, pos Trousseau’s, pos Chvostek’s,

prolonged ST interval, prolonged QT segments

o Mg: 1.5 – 2.5

o Cl: 96 – 106

o Phos: 3 – 4.5

o Albumin: 3.5 – 5

o Specific Gravity: 1.005 – 1.030

o HgbA1C:

 Ideal = 4-6%

 Ok (120 days) <7>

o Dilantin TR: 10 – 20

o Lithium TR: 0.5 – 1.5

o Arterial Blood Gas

 pH = 7.35 – 7.45

 CO2 = 35 – 45

 HCO3 = 22 – 28

 O2 = 80 – 100

 O2 Sat = 95 – 100%

 Antidotes

o Digoxin – Digiband

o Coumadin – Vit K

o Benzos – Flumzaemil (Tomazicon)

o Heparin – Protamine Sulfate (Keep aPTT and PTT at 1.5-2 times normal)

o Tylenol – Mucomyst (loading dose + 17 doses)

o Opiates (narcotics analgesics, heroin, morphine) – Narcan (naloxone)

o Cholinergic meds (myesthenic bradycardia) – Atropine

o Methotrexate – Leucovorin

 Delegation

o RN only

 Blood products (2 RNs must check)

 Clotting factors

 Sterile dressing changes and procedures

 Assessments that require clinical judgment

 Ultimately responsible for all delegated duties

o Unlicensed Assistive Personnel

 Non-sterile procedures

 Precautions and Room Assignments

o 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 of Ambu-bag for resuscitation

 Refrain from giving care if you have skin lesions

o Droplet (Respiratory) Precautions – wear mask

 Sepsis, scarlet fever, strep, fifth disease (Parvo B19), pertusis, pneumonia, influenza, diphtheria,

epiglottitis, rubella, rubeola, meningitis, mycoplasma, adenovirus, rhinovirus

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 RSV (needs contact precautions too)

 TB (Respiratory isolation)

o Contact Precautions = universal + goggles, mask, and gown

o No infectious patients with immunosuppressed patients

 Clean with clean

 Dirty with dirty

 Misc.

o Rifampin (for TB) – rust/orange/red urine and body fluids

o Pyridium (for bladder infection) … Orange/red/pink urine

o Glasgow Coma Scale … < 8>

o Myasthenia Gravis

 Myasthenic Crisis = Weakness with change in vitals (give more meds)

 Cholinergic Crisis = Weakness with no change in vitals (reduce meds)

o Diabetic Coma vs. Insulin Shock … Give glucose first – If no help, give insulin

o Fruity Breath = Diabetic Ketoacidosis

o Acid-Base Balance

 If it comes out of your ass, it’s Acidosis.

 Vomiting = Alkalosis

o Skin Tastes Salty = Cystic Fibrosis

o Lipitor (statins) in PMs only – No grapefruit juice

o Stroke

 Tongue points toward side of lesion (paralysis)

 Uvula deviates away from the side of lesion (paralysis)

o Hold Digoxin if HR < 60>

o Stay in bed for 3 hours after first ACE Inhibitor dose

o Avoid Grapefruit juice with CCBs

o Anthrax = Multi-vector biohazard

o Pulmonary air embolism prevention = Trendelenberg (HOB down) + on left side (to trap air in right side of heart)

o Head Trauma and Seizures – maintain airway = primary concern

o Peptic Ulcers