NCLEX-BASIC NURSING

RBC

4.2-6.2

WBC

4,500-11,000

Platelets

150,000-450,000

Hematocrit

35-52%

Hemoglobin

12-18

Normal Bleeding Time

1.5-9.5 minutes​

PTT

20-39 seconds​

PT

9.5-12 seconds​

INR

1.0 normal
2-3 seconds for a.fib treatment
2.5-3.5 seconds for prosthetic heart valves​

ESR

<30 mm/hr >50 years old
<25 mm/hr if <50 years old
(time that erythrocytes settle in well mixed venous blood)​

Blood Sugar

60-110​ mg/dl

Cholesterol

150-200​

LDL

<160 (<100 if CAD)​

HDL

35-85​

Triglycerides

100-200​

BUN

10-20 g/dL (high=kidney failure)

Cr

0.4-1.4 (high=kidney failure)

Urine Specific Gravity

1.005-1.030

Alkaline Phosphatase

50-120u/L (increased=liver damage)

Creatine Kinase

MM bands present= skeletal muscle damage 
MB bands present= cardiac muscle damage
elevated= MI (>336 Males, >176 Females)​

Albumin

3.5-5.5

ALT and AST

10-40 (high=liver damage/failure)

Bilirubin

<5 in newborns
0.3-1 in adults

Therapeutic Digoxin Level

0.5-2

Sodium

135-145​

Potassium

3.5-5

Calcium

8.6-10.2​

Magnesium

1.3-2.3​

Cranial Nerves

1-Olfactory (smell)
2-Optic (vision)
3-Oculomotor (pupil constriction, raising eyelid)
4-Throclear (down and inward eye movement)
5-Trigminal (jaw movement; face/neck sensation)
6-Abducens (lateral eye movement)
7-Facial (movement/taste)
8-Acoustic (hearing/balance)
9-Glossopharyngeal (pharyngeal/movement, taste)
10-Vagus (swallow/speaking)
11-Spinal Accessory (flex/roatation of the head and shoulder shrugging)
12-Hypoglossal (tongue movement)​

What do you do for a transfusion reaction?

Stop, Restart NS, Save blood/tubing and return to blood bank, Draw blood sample, Urine sample, Monitor for hematuria​

Hemolytic Reaction

From incompatibility--> have N/V, chills, lower back pain, hypotension, increased HR​

Isotonic Fluids

Same concentration as body fluids (NS,LR,D5W)

Hypotonic Fluids

Less concentration than body fluids- pulls water into the cell= cell bursts (1/2NS) given with dehydration​

Hypertonic Fluids

More concentration than body fluids- pulls water out of the cell= cell shrivels (10-15% D, NaBicarb 5%) given for hyponatremia

IV Insertion

Using non dominant hand, place tourniquet 4-6" above, warm area/hand over bed/make a fist to dilate vein
Clean with alcohol inside to outside then with iodine
Insert at 10-30 degree angle and lessen, once you see blood lower 1/4" and remove tourniquet, remove needle and advance catheter
Secure, tubing, infuse​

Rapid Acting Insulin

O=10-30 min P=0.5-3 hr D= 3-6 hr
Lispro, Aspart, Glusine​

Short Acting Insulin

O=30-60 min P= 1-5 hr D= 6-10 hr
Regular

Intermediate Insulin

O=1-2 hr P= 6-12 hr D= 16 hr
NPH

Long Acting Insulin

O=3-4 hr P= cont D=24hr

Meds to take at night

Statins
H2Antagonists
Antisecretory 
Tricyclic
Alpha Adrenergic Blockers​

Meds that interact with grapefruit

Can increase serum drug level-CCB, Statins, Caffeine, SSRIs, Dextromorphan, Sirolimus, Carbamazepine, Buspirone, Midazolam, Sildenafil, Praziquantel, Tacrolimus​

Stoma Care

Will function 3-6 days post op~want a low residue diet 6-8wks post op! Swelling normal in first few days post op pouch opening 1/8 inch larger than stoma, skin barrier under all tapes and to protect skin surrounding stoma, cleanse gently/pat dry, use stoma adhesive/hold pouch for 30 sec when setting and change if seal breaks or if 1/4 full​

Bleeding Precautions

Electric Razor
Soft Toothbrush
Pressure post venipuncture​

Metabolic Alkalosis Causes

Vomiting​

Respiratory Alkalosis Causes

Hyperventilation/Mechanical Vent​

Respiratory Acidosis Causes

Decreased rest stimuli (ex-anesthesia), COPD, Pneumonia, Atelectasis​

Metabolic Acidosis Causes

DKA, Renal failure, Dehydration, Liver failure, Diarrhea, Fistulas​

Normal pH

7.35-7.45​

PaCO2 normal levels

35-45

HCO3

22-26​

Trach Care

Q8H or PRN; hyper O2 prior, suction, remove old dressings, open sterile teach care kit/sterile glove, remove inner cannula (clean with hydrogen peroxide), reinsert, clean stoma with hydrogen peroxide and sterile water, change ties, new sterile dressing (DONT CUT GAUZE)​

Nasal Cannula

1-6L/min​

Face Mask

6-8L/min​

Partial Rebreather

8-11L/min​

Nonrebreather

12L/min​

Venturi Mask

4-8L/min​

Trach Collar

8-10L/min​

Ear Drops for adult vs child

Up and back with adult; down and back for child! After lie on unaffected ear to facilitate absorption​

NGT Insertion

Measure distance from tip of nose to earlobe to bottom of xiphoid process; mark the end with tape~lubricate, insert through nose, offer sips of water/bend head forward (HOB 60-90 degrees)~secure with hypoallergenic tape
MONITOR FOR RESP DISTRESS! (sign that it is misplaced in the lungs

NGT Verication

VERIFY WITH CHEST XRAY
~Aspirate gastric contents and check pH (should be <4 if gastric location)​

NGT Care

Check residual before feedings and Q4H if continuous feeding (hold feeding if >100mL); 15-30mL water before and after each med and feed; admin fluids at room temperature; change bag Q24-72H; HOB 30 when feeding and 30 min post​

Urinary Catheter Insertion (Female)

Explain; assemble equipment, pt in dorsal recumbent position or Sims
Drape with drapes using sterile tech; sterile gloves; lube catheter; place in tray. Separate labia and wipe from meatus towards rectum with iodine swabs; insert 2-3 inches into urethrea after seeing urine; inflate balloon; gentile traction/tape to thigh​

Urinary Catheter Insertion (Male)

Explain; assemble equipment, pt in dorsal recumbent position or Sims
Drape with drapes using sterile tech; sterile gloves; lube catheter; place in tray. Pull foreskin and cleanse in circular motion; hold penis perpendicular to body; insert catheter 6-7 inches; replace foreskin; inflate; tape​

Self Catheterization

Keep catheter 2-4 weeks, make sure to do Q 4-6 Hrs on a schedule; can do sitting or standing; hydrate​

When would you use defibrilation vs cardioversion

Defib for V fib (paddle at R sternal border and over apex of heart) and give 1 mg Epi IVP Q3-5 min
Cardioversion for arrhythmias like Afib (need informed consent)

S/S of shock

Cool/clammy skin; restless; tachycardia; weak pulses; Metabolic Acidosis; Oliguria; shallow/rapid respirations; muscle weakness​

Fluid volume deficit S/S

Thirst (early sign), fever, rapid/weak pulse, increased resp, hypotension, weight loss, anxiety, decreased output, HA, increased specific gravity​

Fluid volume overload S/S

Increased/bounding pulse, periph edema, HTN, muffled heart sounds, JVD, low spec gravity, increased venous pressure, decreased Hct/Hgb/BUN/Na​

DI

Decreased ADH- have excessive urine output, dehydration, thirst, weight loss, weakness, consta, low spec gravity, high Na~NI=I&O, monitor spec gravity and DDAVP/Pitressin​

SIADH

Increased ADH- have anorexia/N/V, decreased output, lethargy, HA, decreased DTR, tachy, decreased NA~NI= restrict intake to 500mL/24 Hr, hypertonic saline, weights, I&O, assess LOC​

Hypokalemia

<3.5- can cause anorexia/N/V, weakness, dysrhythmias
~Supplements/increase intake (bananas, rasins, apricots, oranges, potatoes, carrots, celery)

Hyperkalemia

>5- can cause cardiac arrest, muscle weakness, paralysis, N/D
~Restrict meds with K and foods with K, give sodium polystyrene sulfonate, dialysis, or diuretics

Hyponatremia

<135- can have N, muscle cramps, increased ICP, muscle twitching, confusion~Increase intake (beef broth, tomato juice), IV LR or NS, 
water restriction, I&O, weights​

Hypernatremia

>145- can have fever, delusions, disorientation, thirst, postural hypotension, HTN, tachy~Give hypotonic solution, decrease NA intake, weight​

Hypocalcemia

<8.6- can have confusion, seizures, irritability

~Trousseau's Sign= inflate BP cuff to 20mmHg and have carpal spams=tetany
~Chvostek's Sign= tap facial nerve 2cm anterior to the earlobe= twitching of facial muscles=tetany
~Caution with IV CA! Causes irritation! maintain airway- can have stridor, seizure precautions!! Give vit D also! Exercise​

Hypercalcemia

>10.2- can have muscle weakness, lack of coordination, constipation, depressed reflexes, dysrhythmias
~Important to mobilize patient, increase fluids, and prevent injury and renal calculi formation!​

Hypomagnesemia

<1.3- can have tremors, tetany, seizures, depression, confusion! MG DEPRESSES CNS!
~Increase intake (green veggies, nuts, bananas, oranges, pb, chocolate), monitor cardiac! monitor for dig toxicity! seizure precautions! Test ability t swallow bc dysphagia! 
~Can give Ca to counteract danger of myocardial dysfunction that can occur from mag toxicity and rapid infusions!​

Hypermagnesemia

>2.3- can have hypotensions, facial flushing, weakness, absent DTR, paralysis, deep/shallow respitations EMERGENCY!
~Give IV Calcium gluconate, dialysis, monitor cardiac rhythms, support ventilations; teach pt about OTC drugs that have mag

Rule of 9s

head=9
front torso=18
back=18
each leg=18
each arm=9
groin=1​

Addison's Disease

Hyposecretion of adrenal hormones (mineralcorticoids, glucocorticoids, and androgens)​

S/S of Addison's

weakness, dehydration, falling BP--> shock/coma/death, hyperpigmentation, weight loss, fractures, depression/lethargy, decreased BP--> insulin shock 
~Hormone replacement and high protein and carb and Na/low K​

Cushing's Disease

Hypersecretion of adrenal hormones (mineralcorticoids, glucocorticoids, and androgens)​

S/S of Cushing's

Fatigue, weakness, muscle wasting, purple skin striation, depression, moon face, buffalo hump, masculinazation in females, blood sugar imbalance (increased), can have hyperactivity
~Need surgery and K/low Na/Cal/Carb diet​

R sided HF S/S

Affects periphery; dependent edema, hepatomegaly, cool extremities, anxiety, depression, weight gain​

L sided HF S/S

affects lungs; dyspnea, orthopena, pleural effusion, cheyne stokes respirations, crackles, cough with frothy bloody sputum, fatigue, weakness, cerebral anoxia--> ALOC

Venous Vascular Diseases

Varicose veins, Thrombophlebitis (will be cool/brown and have pain)= elevate legs! use warm/moist packs​

Arterial Vascular Diseases

Atherosclerosis, Raynaud's, Buerger's (will be cool/shiny/cyanotic/pallor)= legs in dependent position; don't cross legs/no smoking​

S/S of anemia

Dyspnea possible; pale, exhaustion, loss of appetite, cold sensitivity, dizziness, HA
~ID and treat cause​

Complication of Dwarfism

Diabetes​

Complication of Acromegaly

Poor vision/coordination- need to provide safety​

Warning signs of Cancer

Change in bowel/bladder
A sore that does not heal
Unusual bleeding or discharge
Thickening or lump in tissue
Indigestion or difficulty swallowing
Obvious change in wart/mole
Nagging cough or hoarseness​

Bradytherapy

Internal Radiation=limit contact to 30 minutes!​

Radiotherapy

External Radiation= avoid lotions/creams/deodorants/perfumes, clean and assess skins, don't expose to sunlight! Wear cotton clothes!​

Neutropenia Precautions

Assess skin integrity Q8H, private room, hand hygiene, no sick visitors, no standing water/flowers, clean room daily, low microbial diet (no salads, peeled fruit/veggies), deep breathing Q4H, body hygiene, inspect IV site

Assisting a patient out of bed

Place hand under knees and shoulder of patient; instruct pt to push elbow into bed at the same time the nurse should life pt shoulders with one arm and swing legs over edge with the other

Assisting a patient to stand

Face the pt with hands grasping each side of rib cage; push nurse's knees against 1 of the pt's; rock pt forward to standing; pivot to sit in a chair 
(have chair on pts strong side)​

Assisting a patient into bed

Move pt towards stronger side; use legs not back; use draw sheets as needed; always have assistant standing by!

Position for prolapsed cord

Trendelnberg (legs higher than head)or knee to chest

Position for shock

Modified Trendelenburg (Feet elevated 20 degrees; knees straight; trunk flat; head slightly elevated)

Position for suppositories

Sims (side lying with upper leg bent)

Position for patient experiencing respiratory distress

HOB 60-90 degrees​

Position to allow for oral secretion drainage

Side lying​

Position post tube feeding

HOB up; R side to promote gastric emptying​

Position for foley insertion

Dorsal Recumbent (supine with knees flexed)​

Positon for liver biopsy

Supine with arms above head​

Position for suspected air embolism

HOB down; L side​

Positon for mom if fetal bradycardia

L side (also give mom O2 and start IV) indicated compression of vena cava/decreased O2 to baby

Using crutches

Support weight on hand piece! Keep crutches 8-10 inches out to the side; elbows flexed 20-30 degrees
UP=good leg then crutches
DOWN= crutches with bad leg then good leg

Using a walker

Flex elbows 20-30 degrees; lift and move walker forward 8-10 inches; step forward with affected leg
Nurse should stand behind pt
SIT=grasp armrest on affected side; shift weight to good leg and hand; lower to chair​

Using a cane

Flex elbow 30 degrees and hold handle; tip of cane should be 15cm lateral to the base of the 5th toe
Hold in hand opposite affected extremity; advance cane and affected leg together; lean on cane when moving good leg
UP=cane and good leg
DOWN=cane and bad leg​

Precautions with Pediculosis/Scabies

Contact Isolation​

Precautions with Samonella

Contact Isolation​

Precautions with Pertussis

Droplet Isolation

Precautions with RSV

Contact Isolation​

Precautions with TB

Airborne Isolation​

Precautions with Mumps

Droplet Isolation​

Precautions with MRSA

Contact Isolation​

Precautions with Hepatitis

Standard Isolation (Contact if diapered)​

Precautions with Herpes Simplex/Zoster

Contact Isolation​

Precautions with CMV (Cytomegalovirus)

Standard + wear goggles when handling urine

Precautions with Influenza B

Droplet Isolation

Precautions with C.Diff

Contact Isolation

Precautions with Meningitis

Droplet Isolation until 24 H of treatment​

Precautions with Measles

Airborne Isolation

Precautions with Rotavirus

Contact Isolation

Precautions for a patient post kidney transplant

Protective Isolation (no visitors!) for 72 H​

Precautions with Pneumonia

Droplet Isolation​

Precautions with Shingles/Chickenpox

Airborne Isolation

Precautions with a suspected infected decubitus ulcer

Contact Isolation​

Diet with lithium therapy

Increase NA

Therapeutic lithium level

1-1.5

S/S of lithium toxicity

N/V/D, fine tremors, slurred speech

IV Pyleogram

XRay of urinary tract
D/C metformin 48H prior, do cleansing enema night prior​

Duodenal Ulcers S/S

Pain 1H after meal

Gastric Ulcers S/S

Pain prior to meal and 2-3H after and during the night

Autonomic Dysreflexia

Severe HA, HTN, sweating, congestion, bradycardia
Seen with SCI-triggered by cold

Buerger's Disease

Inflammation/thrombosis in blood vessels (associated with smoking)- will have digital sensitivity to the cold​

Miller Abbot Tube

Removes fluid from small intestine- used for intestinal decompression and paralytic illeus treatment​

Enwald Tube

For rapid lavage; have suction ready!​

If a patient in PostPartum's fundus is boggy and displaced to the R what should the nurse do?

Tell the patient to use the restroom​

What does restlessness/overactiveness in kids give a clue to?

Pain​

What is the Cerebellum responsible for?

Balance​

What is the Occipital Lobe responsible for?

Vision​

What is the Parietal Lobe responsible for?

Sensory Discrimination​

What is the Temporal Lobe responsible for?

Hearing​

What is the Frontal Lobe responsible for?

Concentration, Language, Personality​

Irritable Bowel Syndrome S/S

Alternating diarrhea and constapation​

Inflammatory Bowel Disease

Chronic diarrhea and vomiting​

ECT

Done for seizures, depression
Use general anesthesia, electric currents travel through brain to trigger brief seizure (back pain after not normal)-give Atropine 30 min prior to decrease secretions

4000 Avenue De Courtrai,

Montreal, Quebec

H3S 1C3 ROOM 201

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