Mark Klimek NCLEX Review - Lecture 12
Modifying phrase - ANSWhich part in a question about prioritization is the most important?
1. Acute beats Chronic
2. Fresh post-op (12 hrs) beats medical or other surgical
3. Unstable beats Stable
4. Tie Breaker Rule: if the above 3 rules result in a tie breaker, the more VITAL ORGAN has the
higher priority - ANSWhat are the 4 rules of prioritization?
- Stable
- Chronic illness
- Post-op > 12 hrs
- Local or regional anesthesia
- Lab abnormalities in the A or B level
- "Ready for discharge", "to be discharged", "admitted > 24 hrs"
- UNCHANGED assessment
- Experience TYPICAL, EXPECTED S/Sx of the disease they're diagnosed with - ANSWhat
word descriptions makes a patient stable?
Creatinine, BUN, Hgb 8-11, Bicarb, elevated Hct, elevated BNP, elevated Na+, abnormal RBCs -
ANSList the A or B level lab abnormalities
- Unstable
- Acute illness
- Post-op < 12 hrs
- General anesthesia in first 12 hrs
- Lab abnormalities in the C or D level
- "Newly diagnosed", "newly admitted", "not ready for discharge", "admitted < 24 hrs"
- CHANGING/CHANGED assessment
- Experiencing UNEXPECTED S/Sx - ANSWhat word descriptions makes a patient unstable?
INR in the 4s, K in the 6s, pH in 6s, CO2 in 50s and 60s, low O2 sat, high WBC, low ANC, low
CD4, low Platelets - ANSList the C or D level lab abnormalities
B - ANSWhich of the following pts is the HIGHEST priority?
A. A 16-year-old female with meningococcal meningitis who has had a temp of 103.8ºF since
she was admitted 3 days ago
B. A 67-year-old male with IBS who spiked a temp of 103.4ºF this afternoon
1. Hemorrhage
2. Hypoglycemia (can cause brain damage)
, 3. Fever > 105ºF (can cause seizure)
4. Pulseless or breathless - ANSWhat 4 patients are ALWAYS unstable?
unwitnessed, low, dead - ANSAt the scene of an __________ accident, pulseless and
breathless pts are ______ priority because they are likely _______.
1. Pulseless
2. Breathless
3. Fixed and dilated pupils (even if they're still breathing) - ANSIn a mass casualty incident, what
3 things result in a BLACK tag?
vital, organ
- Most vital to least vital: brain, lungs, heart, liver, kidney, pancrease - ANSThe more _____ the
_______, the higher the priority
1. Starting a IV
2. Hanging or mixing IV meds
3. Giving an IV push/PB meds (can only maintain an IV and document the flow)
4. Administer blood or deal with central lines (I.e. flush, change dressings)
5. Make care plans (can implement them tho)
6. Perm or develop teaching (can reinforce)
7. Take care of UNSTABLE pts
8. Perform the "FIRST" of anything
9. Assess: admission, d/c, transfer, or first assessment after a change - ANSWhat
responsibilities would you NOT delegate to an LPN?
RN - ANSSomeone heard new crackles on a guy in Room 52. Who should go assess this pt?
1. Chart about a pt, but CAN document what they did
2. Administer medications unless they are TOPICAL, OTC, and barrier creams
3. Assessments, except for VS and Accuchecks (diabetes)
4. Treatments, except for ENEMAS - ANSWhat would you NOT delegate to a UAP?
ADL (activity of daily living), first - ANSThe RN may delegate ______ tasks to a UAP, but the
UAP should never do any of these tasks ______.
Family, safety; Teach - ANSDo not delegate to ________: __________ responsibilities. They
can only do what you ________ them to do.
First 3 are good, NEVER do the last one - ANSHow do you intervene with inappropriate
behavior of staff?
1. Tell the supervisor
2. Intervene immediately
3. Counsel them later on
Modifying phrase - ANSWhich part in a question about prioritization is the most important?
1. Acute beats Chronic
2. Fresh post-op (12 hrs) beats medical or other surgical
3. Unstable beats Stable
4. Tie Breaker Rule: if the above 3 rules result in a tie breaker, the more VITAL ORGAN has the
higher priority - ANSWhat are the 4 rules of prioritization?
- Stable
- Chronic illness
- Post-op > 12 hrs
- Local or regional anesthesia
- Lab abnormalities in the A or B level
- "Ready for discharge", "to be discharged", "admitted > 24 hrs"
- UNCHANGED assessment
- Experience TYPICAL, EXPECTED S/Sx of the disease they're diagnosed with - ANSWhat
word descriptions makes a patient stable?
Creatinine, BUN, Hgb 8-11, Bicarb, elevated Hct, elevated BNP, elevated Na+, abnormal RBCs -
ANSList the A or B level lab abnormalities
- Unstable
- Acute illness
- Post-op < 12 hrs
- General anesthesia in first 12 hrs
- Lab abnormalities in the C or D level
- "Newly diagnosed", "newly admitted", "not ready for discharge", "admitted < 24 hrs"
- CHANGING/CHANGED assessment
- Experiencing UNEXPECTED S/Sx - ANSWhat word descriptions makes a patient unstable?
INR in the 4s, K in the 6s, pH in 6s, CO2 in 50s and 60s, low O2 sat, high WBC, low ANC, low
CD4, low Platelets - ANSList the C or D level lab abnormalities
B - ANSWhich of the following pts is the HIGHEST priority?
A. A 16-year-old female with meningococcal meningitis who has had a temp of 103.8ºF since
she was admitted 3 days ago
B. A 67-year-old male with IBS who spiked a temp of 103.4ºF this afternoon
1. Hemorrhage
2. Hypoglycemia (can cause brain damage)
, 3. Fever > 105ºF (can cause seizure)
4. Pulseless or breathless - ANSWhat 4 patients are ALWAYS unstable?
unwitnessed, low, dead - ANSAt the scene of an __________ accident, pulseless and
breathless pts are ______ priority because they are likely _______.
1. Pulseless
2. Breathless
3. Fixed and dilated pupils (even if they're still breathing) - ANSIn a mass casualty incident, what
3 things result in a BLACK tag?
vital, organ
- Most vital to least vital: brain, lungs, heart, liver, kidney, pancrease - ANSThe more _____ the
_______, the higher the priority
1. Starting a IV
2. Hanging or mixing IV meds
3. Giving an IV push/PB meds (can only maintain an IV and document the flow)
4. Administer blood or deal with central lines (I.e. flush, change dressings)
5. Make care plans (can implement them tho)
6. Perm or develop teaching (can reinforce)
7. Take care of UNSTABLE pts
8. Perform the "FIRST" of anything
9. Assess: admission, d/c, transfer, or first assessment after a change - ANSWhat
responsibilities would you NOT delegate to an LPN?
RN - ANSSomeone heard new crackles on a guy in Room 52. Who should go assess this pt?
1. Chart about a pt, but CAN document what they did
2. Administer medications unless they are TOPICAL, OTC, and barrier creams
3. Assessments, except for VS and Accuchecks (diabetes)
4. Treatments, except for ENEMAS - ANSWhat would you NOT delegate to a UAP?
ADL (activity of daily living), first - ANSThe RN may delegate ______ tasks to a UAP, but the
UAP should never do any of these tasks ______.
Family, safety; Teach - ANSDo not delegate to ________: __________ responsibilities. They
can only do what you ________ them to do.
First 3 are good, NEVER do the last one - ANSHow do you intervene with inappropriate
behavior of staff?
1. Tell the supervisor
2. Intervene immediately
3. Counsel them later on
