ATI NCLEX Tips

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Laboratory Values:Sodium 136-145 mEq/LPotassium 3.5-5.0 mEq/LTotal Calcium 9.0-10.5 mg/dLMagnesium 1.3-2.1 mg/dLPhosphorus 3.0 -4.5 mg/dLBUN10-20 mg/dLCreatinine 0.6 - 1.2mg/dL males, 0.5 - 1.1 mg/dL femalesGlucose 70-105 mg/dLHgbAlc <6.5%WBC 5,000-10,000/mm--RBCMen4.7-6.1 million/mm-:Women4.2-5.4million/mm2Hemoglobin Men 14-18g/100 mL, Women 12-16 g/100 mLHematocritMen 42-52%,Women37-47%Platelet 150,000-400,000/mnrPpH7.35-7.45pC02 35 to45mm Hgp02 80-100 mmHgHCO3 21-26mmol/LNormal PT = 11-12.5sec,Normal INR = 0.7-1.d (Therapeutic INR 2-3)Normal PTT = 30-40 sec (Therapeutic PTT 1.5- 2 x normal or control values)Digoxin 0.5 to 2.0ng/mLLithium 0.8 to 1.4 mEq/LDilantin 10-20 mcg/mLTheophylline 10 to 20mcg/mL1

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Latex Allergies:Note that clients allergic to bananas, apricots, cherries, grapes, kiwis, passion fruit,avocados, chestnuts, tomatoes, and/or peaches may experience latex allergies as well.Ordeof assessment:l-inspectionP-paIpationP-percussionA-auscultationExcept with abdomen it is lAPP-inspect, auscultate, percuss and palpate.Cane walking:C-caneO-oppositeA-affectedL-legCrutch walking:Remember the phase "step up" when picturing a person going up stairs with crutches.The good leg goes up first followed by the crutches and the bad leg. The oppositehappens going down the stairs....OR "up to heaven...down to hellDelegation:RNs DO NOT delegate what they can EAT - evaluate, assess, teachHelpful tool to remember Isolation Precautions:AIRBORNE:"My Chicken Hez TB"-Measles-Chicken pox-Herpes zoster-TBManagement: neg. pressure room, private room, mask, n-95forTB

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DROPLET: ”SPIDERMAn”-Sepsis-Scarlet Fever-Strep-Pertussis-Pneumonia-Parvovirus-Influenza-Diphtheria-Epiglottitis-Rubella-Mumps-AdenovirusManagement: Private room/maskCONTACT: "MRS WEE”-MRSA-VRSA-RSV-Skin infections (herpes zoster, cutaneous diphtheria, impetigo, pediculosis, scabies,and staphylococcus)-Wound infections-Enteric infections (Clostridium difficile)-Eye infections (conjunctivitis)Management: gown, gloves, goggles, private room

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Med-Surg Tips:Angina Precipitating Factors: 4 E'sExertion: physical activity and exerciseEatingEmotional distressExtreme temperatures: hot or cold weatherArterial Occlusion: 4 P'sPainPulselessness or absent pulsePallorParesthesiaCongestive Heart Failure Treatment: MADD DOGMorphineAminophyllineDigoxinDopamineDiureticsOxygenGasses: Monitor arterial blood gassesHeart Murmur Causes: SPASMStenosis of a valvePartial obstructionAneurysmsSepta] defectMitral regurgitationHeart Sounds: All People Enjoy the MoviesAortic: 2nd right intercostal spacePulmonic: 2nd left intercostal spaceErb's Point 3rd left intercostal spaceTricuspid: 4th left intercostal spaceMitral or Apex: 5th left intercostal space

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Hypertension Care: DIURETICDaily weightIntake and OutputUrine outputResponse of blood pressureElectrolytesTake pulseIschemic episodes orTIAsComplications: CVA, CAD. CHF. CRFShortness of Breath (SOB) Causes: 4As+4PsAirway obstructionAnginaAnxietyAsthmaPneumoniaPneumothoraxPulmonary EdemaPulmonary EmbolusStroke Signs: FASTFaceAnnsSpeechTimeCompartment Syndrome Signs and Symptoms: 5 P'sPainPallorPulse declined or absentPressure increasedParesthesiaShock Signs and Symptoms: CHORD ITEMCold, clammy skinHypotensionOliguriaRapid, shallow breathingDrowsiness, confusionIrritabilityT achycardiaElevated or reduced central venous pressureMulti-organ damage

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Hypoglycemia Signs: TIREDTachycardiaIrritabilityRestlessnessExcessive hungerDepression and diaphoresisHypocalcemia Signs and Symptoms: CATSConvulsionsArrhythmias.TetanyStridor and spasmsHypokalemia Signs and Symptoms: 6 L'sLethargyLeg crampsLimp musclesLow, shallow respirationsLethal cardiac dysrhythmiasLots of urine (polyuria)Hypertension Complications: The 4 C'sCoronary artery disease (CAD)Congestive heart failure (CHF)Chronic renal failure (CRF)Cardiovascular accident (CVA): Brain attack or strokeTraction Patient Care: TRACTIONTemperature of extremity is assessed for signs of infectionRopes hang freelyAlignment of both' and injured areaCirculation check (5 P's)Type and location of fractureIncrease fluid intakeOverhead trapezeNo weights on bed or floor

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Cancer Early Warning Signs: CAUTION UPChange in bowel or bladderA lesion that does not healUnusual bleeding or dischargeThickening or lump in breast or elsewhereIndigestion or difficult}’ swallowingObvious changes in wart or moleNagging cough or persistent hoarsenessUnexplained weight lossPernicious AnemiaLeukemia Signs and Symptoms: ANTAnemia and decreased hemoglobinNeutropenia and increased risk of infectionThrombocytopenia and increased risk of bleedingClients Who Require Dialysis: AEIOU (The Vowels)Acid base imbalanceElectrolyte imbalancesIntoxicationOverload of fluidsUremic symptomsAsthma Management: ASTHMAAdrenergics: Albuterol and other bronchodilatorsSteroidsTheophyllineHydration: intravenous fluidsMask: oxygen therapyAntibiotics (for associated respiratory infections)Hypoxia: RAT (signs of early) BED (signs of late)RestlessnessAnxietyTachycardia and tachypneaBradycardiaExtreme restlessnessDyspnea

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Pneumothorax Signs: P-THORAXPleuritic painTracheal deviationHyperresonanceOnset suddenReduced breath sounds (and dyspnea)Absent fremitusX-ray shows collapsed lungTransient Incontinence Causes: DIAPERSDeliriumInfectionAtrophic urethraPharmaceuticals and psychologicalExcess urine outputRestricted mobilityStool impactionDealing with Constipation:Constipation is difficult or infrequent passage of stools, which may be hard and dry.Causes include: irregular bowel habits. psychogenic factors, inactivity. chronic laxative use orabuse, obstruction, medications, and inadequate consumption of fiber and fluid.Encouraging exercise and a diet high in fiber and promoting adequate fluid intake may helpalleviate symptoms.Dealing with Dysphagia:Dysphagia is an alteration in the client's ability to swallow.Causes include:ObstructionInflammationEdemaCertain neurological disordersModifying the texture of foods and the consistency of liquids may enable the client to achieveproper nutrition.Clients with dysphagia are at an increased risk of aspiration. Place the client in an upright orhigh-Fowlef s position to facilitate swallowing.Provide oral care prior to eating to enhance the client's sense of taste.Allow adequate time for eating, utilize adaptive eating devices. and encourage small bites andthorough chewing.Avoid thin liquids and sticky foods.

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Dumping Syndrome:Dumping Syndromeoccurs as a complication of gastric surgeries that inhibit the ability of thepyloric sphincter to control the movement of food into the small intestine.This "dumping" results in nausea, distention, cramping pains, and diarrhea within 15 min aftereating.Weakness, dizziness, a rapid heartbeat, and hypoglycemia may occur.Small, frequent meals are indicated.Consumption of protein and fat at each meal is indicated.Avoid concentrated sugars.Restrict lactose intake.Consume liquids 1 hr before or after eating instead of with meals (a dry diet).Gastroesophageal Reflux Disease (GERD):GERDleads to indigestion and heartburn from the backflow of acidic gastric juices onto themucosa of the lower esophagus.Encourage weight loss for overweight clients.Avoid large meals and bedtime snacks.Avoid trigger foods such as citrus fruits and juices, spicy foods, and carbonated beverages.Avoid items that reduce low'er esophageal sphincter (LES) pressure, such as alcohol, caffeine,chocolate, fatty foods, peppermint and spearmint flavors, and cigarette smoking.Peptic Ulcer Disease (PUD):PUDis characterized by an erosion of the mucosal layer of the stomach or duodenum.This may be caused by a bacterial infection withHelicobacter pylorior the chrome use ofnon-steroidal anti-inflammatory drugs (NSAIDs), such as aspirin and ibuprofen.Avoid eating frequent meals and snacks, as the}' promote increased gastric acid secretion.Avoid alcohol, cigarette smoking, aspirin and other NSAIDs, coffee, black pepper, spicy foods,and caffeineLactose Intolerance:Lactose intolerance results from an inadequate supply of lactase, the enzyme that digestslactose.Symptoms include distention, cramps, flatus, and diarrhea.Clients should be encouraged to avoid or limit their intake of foods high in lactose such as: milk,sour cream, cheese, cream soups, coffee creamer, chocolate, ice cream, and puddings.Diverticulosis and Diverticulitis:A high-fiber diet may preventdiverticulosis and diverticulitis byproducing stools that areeasily passed and thus decreasing pressure within the colon.During acute diverticulitis, a low’-fiber diet is prescribed in order to reduce bowel stimulation.Avoid foods with seeds or husks.Clients requue instruction regarding diet adjustment based on the need for an acute inten’entionor preventive approach.

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Cholecystitis:Cholecystitisis characterized by inflammation of the gallbladder. The gallbladder stores andreleases bile that aids in the digestion of fats.Fat intake should be limited to reduce stimulation of the gallbladder.Other foods that may cause problems include coffee, broccoli, cauliflower. Brussels sprouts,cabbage, onions, legumes, and highly seasoned foods.Otherwise, the 'diet is individualized to the client's needs and tolerance.Nephrotic Syndrome:Nephrotic syndromeresults in serum proteins leaking into the urine.The goals of nutritional therapy are to minimize edema, replace lost nutrients, and minimizepermanent renal damage.Dietarc recommendations indicate sufficient protein and low-sodium intake.Nephrolithiasis (Kidney Stones):Increasing fluid consumption is the primary intemention for the treatment and prevention of theformation ofrenal calculiExcessive intake of protein, sodium, calcium, and oxalates (rhubarb,spinach, beets) may increase the risk of stone formation.Acute Renal Failure (ART):AREis an abrupt, rapid decline in renal function. It is usually caused by trauma, sepsis, poorperfusion, or medications. ARE can cause hyponatremia, hyperkalemia, hypocalcemia, andhyperphosphatemia. Diet therapy for ARE is dependent upon the phase of xARF and itsunderlying cause.

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Pre-End Stage Renal Disease Ipre-ESRD):Pre-ESRD, or diminished renal reserve renal insufficiency, is a predialysis condition characterized by anincrease in serum creatinine.Gcals of nutritional therapy for pre-ESRD are to:Help preserve remaining renal function by limiting the intake of protein and phosphorus.Control blood glucose levels and hypertension. which are both risk factors.Protein restriction is key for clients with pre-ESRD.Slows the progression of renal disease.Too little protein results in breakdown of body protein, so protein intake must be carefully determined .Restricting phosphorus intake slows the progression of renal disease.High levels of phosphorus contribute to calcium and phosphorus deposits in the kidneys.Dietary recommendations for pre-ESRD:Limit meat intake.Limit dairy products to W cup per day.Limit high-phosphorus foods (peanut butter, dried peas and beans, bran, cola, chocolate, beer, some wholegrains).Restrict sodium intake to maintain blood pressure.Caution clients to use vitamin and mineral supplements ONLY when recommended by tlreir provider.End Stage Renal Disease (ESRD):ESRD. or chronic renal failure, occurs when the glomerular filtration rate (GFR) is less than 25 mL min.the serum creatinine level steadily rises, or dialysis or transplantation is required.The goal of nutritional therapy is to maintain appropriate fluid status, blood pressure, and bloodchemistries.A high-protein, low-phosphorus. low-pota&sium, low-sodium. fluid-restricted diet is recommended.Calcium and vitamin D are nutrients of concern.Protein needs increase once dialysis is begun because protein and amino acids are lost in the dialysate.Fifty percent of protem intake should come from biologic sources (eggs, milk, meat, fish, poultry, soy).Adequate calories (35 cal kg of body weight) should be consumed to maintain body protein stores.Phosphorus must be restricted.The high protein requirement leads to an increase in phosphorus intake.Phosphate binders must be taken with all meals and snacks.Vitamin D deficiency occurs because the kidneys are unable to convert it to its active form.This alters the metabolism of calcium, phosphorus, and magnesium and leads to hyperphosphatemia,hypocalcemia, and hypermagnesemia.Calcium supplements will likely be required because foods high in phosphorus (which are restricted) arealso high in calcium.Potassium intake is dependent upon the client's laboratory values, which should be closely monitored.Sodium and fluid allowances are determined by blood pressure, weight, serum electrolyte levels, andurine output.Achieving a well-balanc ed diet based on the above guidelines is a difficult task. The National Renal Dietprovides clients with a list of appropriate food choices.

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Cleft lip: nursing care plan (postoperative) — "CLEFT LIPCrying, minimizeLogan bowElbow restraintsFeed with Brecht feederTeach feeding techniques; two months of age (average age at repair)Liquid (sterile water), rinse after feedingImpaired feeding (no sucking)Position—never on abdomenComplication of severe preeclampsia — "HELLP"syndromeHemolysisElevated Liver enzymesLow Platelet countDystocia: general aspects (maternal)—'MP's"PowersPassagewayPassengerPsychInfections during pregnancy — "TORCH"ToxoplasmosisOther (hepatitis B, syphilis, group B beta strep)RubellaCytomegalovirusHerpes simplex virusIUD: potential problems with use — "PAINS"Period (menstrual: late, spotting, bleeding)Abdominal pain, dyspareuniaInfection (abnormal vaginal discharge)Not feeling well, fever or chillsString missingNewborn assessment components — "APGAR"AppearancePulseGrimaceActivityRespiratory effort

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Obstetric (maternity) history — "GTPAL"GravidaTermPretermAbortions (SAB, TAB)Living childrenOral contraceptives: Signs of potential problems —"ACHES"Abdominal pain (possible liver or gallbladder problem)Chest pain or shortness of breath (possible pulmonary embolus)Headache (possible hypertension, brain attack)Eye problems (possible hypertension or vascular accident)Severe leg pain (possible thromboembolic process)Preterm infant: Anticipated problems — "TRIES"Temperature regulation (poor)Resistance to infections (poor)Immature liverElimination problems (necrotizing enterocolitis [NEC])Sensory-perceptual functions (retinopathy of prematurity [ROP])VEAL CHOP-which relates to fetal heart rate.Variable decels => Cord compression (usually a change in mothers position helps)Early decels => Head compression (decels mirror the contractions; this is not a sign offetal problems)Accelerations => O2(baby is well oxygenated-this is good)Late decels => Placental utero insufficiency (this is bad and means there is decreasedperfusion of blood/oxygen/nutrients to the baby).Nine-point Postpartum Assessment...BUBBLEHERB- BreastsU- UterusB- BladderB- Bov el functionL- LochiaE- EpisiotomyH- HemorrhoidsE- Emotional StatusR- Respiratory System

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Considerations for the pregnant clientAdmittance of a pregnant client to a medical-surgical unit:You may have a pregnant client admitted with a diagnosis unrelated to her pregnancyand, therefore, she may be admitted to a general medical-surgical floor. A mnemonic toassist you in performing important assessment elements for these clients is FETUS.* F:Document fetal heart tones every shift. To assess fetal heart tones, use a handheldDoppler ultrasound and place it in an area corresponding to uterine height. Forexample, for a client who’s less than 20 weeks pregnant, the most likely area to findfetal heart tones is at the pubic hairline or the symphysis pubis. For a client whosepregnancy is more advanced, such as at 24 weeks, the fetal heart rate can mostprobably be heard midline between the symphysis pubis and the umbilicus. As thepregnancy advances in weeks, fetal heart tones can be heard closer to and possiblyabove the umbilicus.* EProvide emotional support. Pregnant women who are experiencing unexpectedmedical conditions are at a high level of anxiety related to how the current medicalproblem may affect the fetus. You should take extra care to alleviate and reduce yourclient's anxiety by explaining all medications and treatments. Additionally, be preparedto listen for fetal heart tones anytime the client requests it to further reduce her worry ofthe fetus' well-being.* T: Measure maternal temperature. Because your client's core body temperature ishigher than you can detect through oral or tympanic thermometers, be alert to thepresence of a fever. A high maternal temperature can lead to fetal tachycardia anddistress. An order for antipyretics on admission to ensure their quick availability will be aprudent request you should make to the admitting physician.* U: Ask about uterine activity or contractions. Make it a normal part of your routine toask about any type of uterine pain, tightening, or discomfort throughout your shift. Beaware that early contractions often present as lower back pain. Don't attributecomplaints of lower back pain to the hospital bed. If your client reports any unusualactivity, take care to softly palpate the lower abdomen for periods of greater than 2minutes while conversing with her. Watch for subtle changes of facial expression whilesimultaneously detecting a change in uterine tone. If contractions are suspected, yourclient will need to be monitored with continuous fetal monitoring in the labor and deliveryunit.* S:Assess for the presence of and changes in sensations of fetal movement. After 20weeks gestation, all women should be able to report feeling the fetus move. This is animportant assessment to perform and document at least every shift, easilyaccomplished by asking "How often are you feeling the baby move?" By asking this asan open-ended question, you'll receive more information about the quantity of fetalmovement such as, "I haven't felt the baby move as much as usual today."

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Admittance of a postpartum client to a medical-surgicalunitThere are times when a woman may be hospitalized during the postpartum period for amedical condition. When this occurs, she'll most likely be placed on a generalmedical-surgical unit. Her admission will cause you to ask: "What's normal during theweeks following the birth of a baby?"* Breasts Within the first 24 hours postpartum, colostrum appears and is followed bybreast milk within the first 72 hours. Breast engorgement is most likely to occur aroundday 4 postpartum. The engorged breast will appear full, taut and even shiny. Althoughthis is normal, it may be very uncomfortable for your client In contrast, a woman withmastitis will usually run a fever higher than 100" F, report feeling "ill," and have onebreast that's affected (firm, inflamed, swollen, and exquisitely tender to touch). If yourclient is breastfeeding her newborn, she'll require a breast pump. Depending on themedications ordered, the milk may need to be disposed of and not used for the baby.* Lochia. Sometimes women will experience lochia (vaginal discharge) until the time oftheir 6-week postpartum visit. Immediately after delivery, the lochia is red and heavyenough to require a pad change every 1 to 2 hours. By 7 days postpartum, the lochiashould be lighter in color (pink to red) and amount, requiring a pad change every 4hours. Lochia that becomes heavier, has a foul odor, and is accompanied by pelvic painisn’t a normal finding and requires immediate intervention.* Perinea/ care. For the first 2 weeks following delivery, clients will need to performperineal hygiene as taught during the immediate postpartum period. This may includeperineal water rinses following elimination using warm water or medicinal rinses, use ofsitz baths, and comfort medications to the perineal and anal area.* Cesarean section. If your client delivered her baby via cesarean section, continuedassessment of the surgical incision is warranted for the first 2 to 3 weeks postpartum.Redness and warmth around the incision, excessive bruising around the incision, orincisional drainage requires immediate intervention. If the surgeon used staples to closethe incision, they're usually removed approximately 5 days post-delivery.Remember, the hospitalized postpartum client is likely to be very emotional. Not only willshe be experiencing the normal hormonal fluctuations of the postpartum period, shemay also be distraught leaving her newborn at home and feeling that she's missingbonding lime with her child. Visitation between the mother and her infant may be verylimited to minimize the infant's risk of infection, but visits should be arranged if at allpossible.

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