NCLEX TIPS Emma’s Test Taking Strategies

NCLEX TIPS Emma’s Test Taking Strategies 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  Unexpected finding with Disease Process 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. Second Hand Info  Any time you have 2nd hand info, the right answer is asses • 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 3) Redirect – Dementia Emma’s 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’s 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 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: • Do respond to feeling tone • Do provide information • Do focus on the client • Do use silence • Do use presence • Do not ask ‘why’ questions • Do not ask ‘yes/no’ questions, except in the case of possible self-harm • Do not focus on the nurse • Do not explore • 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 buck. • 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 Important Lab Values Cholesterol HDL 50 LDL 100 Triglycerides 150 Total Cholesterol 200 Albumin level 3.5 to 5.5 Therapeutic PTT: 1.5 – 2x the normal value (46 – 76 Seconds) Therapeutic Ranges 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 Arterial Blood Gases 1. Prior to drawing an AGB, 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. Antidotes • Aspirin  Activated Charcoal • Coumadin (Warfarin)  Vitamin K • Heparin  Protamine Sulfate • Tylenol (Acetaminophen)  Mucomyst (acetylcysteine) – administered orally • Digoxin (Lanoxin)  Digibind (immune Fab) • Opioids  Narcan • Iron overdose  Deferoxamine • PCP  Activated charcoal • Magnesium Sulfate  Calcium Gluconate • TPA  Amicar • Pancuronium Bromide  Neostigmine/Atropine Blood For blood types: • "O" is the universal donor (remember "o" in donor) • "AB" is the universal recipient Blood transfusion – sign of allergies in order: 1)Flank pain 2)Frequent swallowing 3)Rashes 4)Fever 5)Chills Sickle Cell Anemia Thrombocytopenia – Bleeding precautions! 1)Soft bristled toothbrush 2) No insertion of anything! (c/i suppositories, douche) 3) No IM meds as much as possible! During sickle cell crisis there are two interventions to prioritize: fluids and pain relief. Iron deficiency anemia – easily fatigued 1)Fe PO - give with Vitamin C or on an empty stomach 2)Fe via IM- Inferon via Ztrack Pernicious Anemia - s/s include pallor, tachycardia, and Sore Red, Beffy tongue; will take Vit.B12 for life! Shilling Test – test for pernicious anemia/ how well one absorbs Vit b12 General Notes • A patient with a low hemoglobin and/or hematocrit should be evaluated for signs of bleeding, such as dark stools. Burns Rule of nines, 9 = head, 18 = arms, 36 = torso, 36 =legs, and 1= perineum = 100% The Parkland formula is a formula used for calculation the total fluid requirement in 24 hours for a burn patient 4ml x TBSA % (Total Burn Surface Area) x body weight (kg) = Total amount of fluid the patient will receive in 24 hrs 50% given in first eight hours 50% given in next 16 hours. The Number #1 Priority for Burn Patients is maintaining a patent airway 1st Degree – Red and Painful 2nd Degree – Blisters 3rd Degree – No Pain because of blocked and burned nerves Cancer A cancer patient is getting radiation. What should the nurse be most concerned about? • Skin irritation? No. • Infection kills cancer patients most because of the leukopenia caused by radiation. General Notes • A breast cancer patient treated with Tamoxifen should report changes in visual acuity, because the adverse effect could be irreversible. • Common sites for metastasis include the liver, brain, lung, bone, and lymph. • Bence Jones protein in the urine confirms multiple myeloma • Patients with leukemia may have epistaxis (nosebleeds) b/c of low platelets Cardiac All – Aortic Valve Physicians – Pulmonary Valve Earn – Erb’s Point Take – Tricuspid Valve Money – Mitral Valve Or APE To Man Cardiac Catheter • Pre Op – NPO 8-12hr prior, empty bladder, check pulses, tell pt they may feel heat, palpitations, or desire to cough with dye injection. • Post Op – V/S, & keep leg straight, bedrest 6-8 hrs General Notes • Blood tests for MI: Myoglobin, CK and Troponin • Coarctation of the aorta causes increased blood flow and bounding pulses in the arms • Cor Pulmonae is right sided heart failure caused by left ventricular failure; (so pick edema, jvd, if it is a choice.) • Normal PCWP (pulm capillary wedge pressure) is 8-13. Readings of 18-20 are considered high. • Pulmonary sarcoidosis (an inflammatory disease) leads to right sided heart failure. • Anytime you see fluid retention. Think heart problems first. Circulation EleVate Veins; dAngle Arteries for better perfusion For PVD remember DAVE (Legs are Dependent for Arterial & for Venous Elevated) VIRchow’s Triad  Risk Factors for DVT V – Vascular Trauma I – Increased Coagulability R – Reduced Blood Flow –Definitive diagnosis for abd. aortic aneurysm (AAA)  CT scan Fat Embolism S/S • Blood tinged sputum (r/t inflammation) • inc ESR • Respiratory alkalosis (not acidosis r/t tachypnea) • Hypocalcemia,increased serum lipids • "Snow Storm" effect on CXR General Notes • Hypotension and vasoconstricting meds may alter the accuracy of o2 sats. • A newly diagnosed hypertension patient should have BP assessed in both arms Cranial Nerves Sensory=S Motor=M Both=B 1. Oh (Olfactory I) Some 2. Oh (Optic II) Say 3. Oh (Oculomotor III) Marry 4. To (Trochlear IV) Money 5. Touch (Trigeminal V) But 6. And (Abducens VI) My 7. Feel (Facial VII) Brother 8. Very (Vestibulocochlear/Auditory VIII) Says 9. Good (Glossopharyngeal IX) Big 10. Velvet (Vagus X) Brains 11. Such (Spinal Accessory XI) Matter 12. Heaven (Hypoglassal XII) More Cultural Greek heritage - they put an amulet or any other use of protective charms around their baby's neck to avoid "evil eye" or envy of others Lymes Disease is found mostly in Connecticut Jewish Folks: no meat and milk together Diabetes Blood Sugar ~ Hyperglycemia – Hot & Dry ~ Sugar High Hypoglycemia – Cold & Clammy ~ Need some candy To remember how to draw up INSULIN think: Nicole Richie RN Air into NPH, then air into Regular, draw up Regular insulin then draw up NPH Oral Hypoglycemics • Do not attempt to give an oral hypoglycemic to an unconscious pt, as this poses the risk of aspirations • A typical adverse reaction is rash, photosensitivity. HbA1c – test to assess how well blood sugars have been controlled over the past 90-120 days. 4- 6 corresponds to a blood sugar of 70-110; 7 is ideal for a diabetic and corresponds to a blood sugar of 130 Fluids are the most important intervention with HHNS as well as DKA, so get fluids going first. DKA • While treating DKA, bringing the glucose down too far and too fast can result in increased intracranial pressure d/t water being pulled into the CSF. • Serum acetone and serum ketones rise in DKA. • As you treat the acidosis and dehydration expect the potassium to drop rapidly, so be ready, with potassium replacement. HHNK • With HHNS there is no ketosis, and no acidosis. • Potassium is low in HHNS (d/t diuresis General Notes • Extra insulin may be needed for a patient taking Prednisone (remember, steroids cause increased glucose). • Second voided urine most accurate when testing for ketones and glucose. Drugs General Notes • Give NSAIDS, Corticosteroids, drugs for Bipolar, Cephalosporins, and Sulfanomides WITH food. • Best time to take Growth Hormone PM, Steroids AM, Diuretics AM, Aricept AM. • Antacids are given after meals • Remember the action of vasopressin because it sounds like “press in”, or vasoconstrict. • If mixing antipsychotics (ie Haldol, Throazine, Prolixin) with fluids, meds are incompatible with caffeine and apple juice • The main hypersensitivity reaction seen with antiplatelet drugs is bronchospasm (anaphylaxis). • Glucagon increases the effects of oral anticoagulants. • All psych meds' (except Lithium) side effects are the same as SNS but the BP is decreased o SNS- Increase in BP, HR and RR (dilated bronchioled), dilated pupils (blurred vision), Decreased GUT (urniary retention), GIT (constipation), Constricted blood vessels and Dry mouth. Antianemics • Iron injections should be given Z-track so they don't leak into SQ tissues. • Take iron elixir with juice or water never with milk Antiarrhythmics • Calan (verapamil): a calcium channel blocker, used to tx HTN, angina; assess for constipation • Digoxin: Check pulse, if it’s less than 60 hold medication, prior to administration check both potassium and dig levels o Pick ‘do vitals’ before administering that dig. (apical pulse for one full minute). o Making sure that patients on Dig and Lasix are getting enough potassium, because low potassium potentiates Dig toxicity and can cause dysrrhythmias. o o Digitalis increases ventricular irritability, and could convert a rhythm to v-fib following cardioversion. • Adenosine: is the tx of choice for paroxysmal atrial tachycardia. • Flecainide (Tambocor): limit fluids and sodium intake, because sodium increases water retention which could lead to heart failure. Antianxiety • Diazepam is a commonly used tranquilizer given to reduce anxiety before OR • Versed: an anesthetic given for conscious sedation, watch out for respiratory depression and hypotension • Librium: tx of alcohol withdrawal; dont take alchol with this medication is causes n/v • Vistaril: tx of anxiety as well as itching, commonly administered pre-op, watch out for dry mouth • Ativan: tx of choice for status epilepticus Antiasthmatics • INtal: an inhaler used to treat allergy induced asthma may cause bronchospasm, think... INto the asthmatic lung Antibiotic • Aminoglycocides: Adverse Effects are bean shaped - Nephrotoxic to Kidneys and Ototoxic to Ears o Mycin (drugs that end in or have in their name); except erythromycine • Bactrim: an antibiotic; common side effect is diarrhea (drink plenty of fluids); do not take if allergic to sulfa drugs Anticholinergic • Anticholinergic effects –– assessment o dry mouth – can't spit o urinary retention – can't piss o constipated – can't shit o blurred vision – can't see • Atropine used to decrease secretions & asystole o Atropine blocks acetylcholine (remember it reduces secretions) o Atropine OD Hot as a Hare (Temp) Mad as a Hatter (LOC) Red as a Beet (flushed face) Dry as a Bone (Thirsty) • Cogentin: Treats Parkinson as well as extrapyramidal side effects of other drugs Anticonvulsants • Dilantin: tx of seizures; therapeutic drug level: 10-20; contraindicated during pregnancy; Side effects include rash (stop med if seen), gingival hyperplasia (can be prevented w/ good hygiene). o Dilantin Toxicity  poor gait + coordination, slurred speech, nausea, lethargy, & diplopia • Phenobarbital: tx of epilepsy; can be taken during pregnancy Antidepressants • Zoloft: side effects include agitation, sleep disturb, and dry mouth • MAOI’s: antidepressant o An easy way to remember MAOI'S! think of PANAMA! PA – parnate NA - nardil MA - marplan o MAOI's used for depression all have an arrr sound in the middle (Parnate, Marplan, Nardil) – Remember that Pirates say arrrr, so think “pirates take MAOI's when they're depressed” o They have metallic bitter ta