NCLEX-RN Notes: Core Review and Exam Prep (2007)

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Bonus CD-ROM Includes—• 1000plus NCLEX-style questions• Rationales for correct and incorrect responses• Alternate format questions• Strategic tips for successfully answering questionsAll questions coded for—• Client Need• Content Area• Cognitive Domain• Difficulty LevelAll combined to promote success on NCLEX examinations

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Minimum System RequirementsPCCPU:Pentium III or higher64 MB Ram; 128 MB Ram preferred800 x 600 monitor with thousands of colorsOS: Windows/2000/XP8x CD-ROM drive135 MB hard disk spaceLICENSE AGREEMENT1. F. A. Davis (“FAD”) grants the recipient of theNCLEX-RN®Notes: CoreReview & Exam Prep, limited license for the program on the enclosed CD-ROM (“Software”). FAD retains complete copyright to the Software andassociated content.2. Licensee has nonexclusive right to use this copy of the Software on onecomputer on one screen at one location. Any other use is forbidden.3. Licensee may physically transfer the Software from one computer toanother, provided that it is used on only one computer at any one time.Except for the initial loading of the Software on a hard disk or for archivalor backup purposes, Licensee may not copy, electronically transfer, orotherwise distribute copies.4. This License Agreement automatically terminates if Licensee fails tocomply with any term of this Agreement.5. SOFTWARE UPDATES. Updated versions of the Software may be createdor issued by FAD from time to time. At its sole option, FAD may makesuch updatesavailable to the Licensee or authorized transferees whohave returned the registration card, paid the update fee, and returned theoriginal CD-ROM to FAD.

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LIMITED WARRANTY AND DISCLAIMERFAD warrants that the CD-ROM on which the Software is furnished will befree from defects of sixty (60) days from the date of delivery to you by FADor FAD’s authorized representative or distributor. Your receipt shall beevidence of the date of delivery. The Software and accompanying materialsare provided “as is” without warranty of any kind. The complete risk as toquality and performance of a nonwarranted program is with you.FAD makes no warranty that the Software will meet your requirements orthat Software operation will be uninterrupted or error free or that Softwaredefects are correctable. No oral or written information or advice given byFAD, its dealers, distributors, agents, or employees shall create warranty orin any way increase the scope of this limited warranty.REMEDIES.FAD’s entire liability and your exclusive remedy shall be limitedto replacing the defective media if returned to FAD (at your expense)accompanied by dated proof of purchase satisfactory to FAD not later thanone week after the end of the warranty period, provided you have firstreceived a Return Authorization by calling or writing FAD in advance. Themaximum liability of FAD and its licensors shall be the purchase price of theSoftware. In no event shall FAD and its licensors be liable to you or anyother person for any direct, indirect, incidental, consequential, special,exemplary, or punitive damages for tort, contract, strict liability, or othertheory arising out of the use of, or inability to use, the Software.ENTIRE AGREEMENT.This Agreement contains the entire understanding ofthe parties hereto relating to the subject matter hereof and supersedes allprior representations or agreements.GOVERNING LAW.This Agreement and Limited Warranty are governed bythe laws of the Commonwealth of Pennsylvania. All warranty matters shouldbe addressed to F.A. Davis, Publishers, 1915 Arch Street, Philadelphia, PA19103.INSTALLATION INSTRUCTIONSWindowsStep 1.Insert CD into your CD-ROM drive.Step 2.After a few moments, the CD-ROM menu will automatically open.Step 3.Select the item to installIf the CD-ROM Menu does not automatically open, from the START Menu,select RUN and enter X:\SETUP.EXE (where “X” is the letter of your CD-ROMdrive) and select OKFor Technical Support, e-mail: support@fadavis.com

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NCLEX-RN®NotesPurchase additional copies of this book atyour health science bookstore or directlyfrom F. A. Davis by shopping online atwww.fadavis.com or by calling 800-323-3555 (US) or 800-665-1148 (CAN)A Davis’s Notes BookBarbara A. Vitale, RN, MANCLEX-RN®NotesCore Review & Exam PrepCore Review & Exam Prep

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F. A. Davis Company1915 Arch StreetPhiladelphia, PA 19103www.fadavis.comCopyright © 2007 by F. A. Davis CompanyAll rights reserved. This book is protected by copyright. No part of it may bereproduced, stored in a retrieval system, or transmitted in any form or by anymeans, electronic, mechanical, photocopying, recording, or otherwise, withoutwritten permission from the publisher.Printed in China by ImagoLast digit indicates print number: 10 9 8 7 6 5 4 3 2 1Publisher, Nursing:Robert G. MartoneProject Editor:Padraic MaroneyManager of Art and Design:Carolyn O’BrienContent Development Manager:Darlene PedersenContributing Author:Mary Ann Hellmer-Saul, RN, AAS, BS, MS, PhD, ANPConsultants:Paula A. Olesen, RN, MSN; Daryl Boucher, MSN, RN, CCEMTP; GoldenTradewell, PhD, RN; Kathy Whitley, RN, MSN, FNP; Leesa A. McBroom, MSN, APRN,FNP-C; Lindsey L. Carlson, MSN, RN; Eileen Kaslatas, MSN, RN; Joanne Vitale, RPA-C, BA; William Hendricks, RPh; Jean Prochilo, RN, BS; Nina Goldsztejn, RN, BC,BSN, MSN, NPAs new scientific information becomes available through basic and clinicalresearch, recommended treatments and drug therapies undergo changes. Theauthor(s) and publisher have done everything possible to make this book accurate,up to date, and in accord with accepted standards at the time of publication. Theauthors, editors, and publisher are not responsible for errors or omissions or forconsequences from application of the book, and make no warranty, expressed orimplied, in regard to the contents of the book. Any practice described in this bookshould be applied by the reader in accordance with professional standards of careused in regard to the unique circumstances that may apply in each situation. Thereader is advised always to check product information (package inserts) for changesand new information regarding dose and contraindications before administeringany drug. Caution is especially urged when using new or infrequently ordereddrugs.Authorization to photocopy items for internal or personal use, or the internal orpersonal use of specific clients, is granted by F.A. Davis Company for usersregistered with the Copyright Clearance Center (CCC) Transactional ReportingService, provided that the fee of $.10 per copy is paid directly to CCC, 222Rosewood Drive, Danvers, MA 01923. For those organizations that have beengranted a photocopy license by CCC, a separate system of payment has beenarranged. The fee code for users of the Transactional Reporting Service is:8036–1570/07 0$.10.

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Look for our otherDavis’s Notes titlesAvailable Now!RNotes®:Nurse’s Clinical Pocket GuideISBN: 0-8036-1335-0LPN Notes:Nurse’s Clinical Pocket GuideISBN: 0-8036-1132-3MedNotes:Nurse’s Pharmacology Pocket GuideISBN: 0-8036-1109-9MedSurg Notes:Nurse’s Clinical Pocket GuideISBN: 0-8036-1115-3NutriNotes:Nutrition & Diet Therapy Pocket GuideISBN: 0-8036-1114-5IV Therapy Notes:Nurse’s Clinical Pocket GuideISBN: 0-8036-1288-5PsychNotes:Clinical Pocket GuideISBN: 0-8036-1286-9LabNotes:Pocket Guide to Lab & Diagnostic TestsISBN: 0-8036-1265-6

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Contacts • Phone/E-MailName:Ph:e-mail:Name:Ph:e-mail:Name:Ph:e-mail:Name:Ph:e-mail:Name:Ph:e-mail:Name:Ph:e-mail:Name:Ph:e-mail:Name:Ph:e-mail:Name:Ph:e-mail:Name:Ph:e-mail:Name:Ph:e-mail:Name:Ph:e-mail:Name:Ph:e-mail:

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1NCLEX-RN®■The National Council Licensure Examination for registered nurses(NCLEX-RN®)measures the knowledge and abilities necessary for entry-level nurses.■It is administered by Computer Adaptive Testing (CAT), whichindividualizes tests to match the unique competencies of each test taker.■Each exam adheres to the NCLEX-RN® Test Plan, which describes thecontent and scope of RN competencies.■Practices basic to nursing (e.g., nursing process, caring, teaching,learning, communication, documentation) are integrated throughout,and most questions require application and analysis of information.NCLEX-RN®Test Plan—Distribution of ContentPatient Needs and % of ItemsSafe and Effective Care Environment■Management of Care■Safety/Infection ControlHealth Promotion and MaintenancePsychosocial IntegrityPhysiological Integrity■Basic Care/Comfort■Pharmacological/Parenteral gfd Therapies■Reduction of Risk Potential■Physiological AdaptationTaking the NCLEX-RN® Test on a Computer■First: You will receive general information about the exam and the testingcenter. Your time spent on this will not count.■Second: You will take a tutorial on how to use the computer to answer thequestions on NCLEX-RN®. Your answers will not count toward your score,but the time you take will be subtracted from the total 6 hours you havefor the exam.■Third: You will then be presented with real NCLEX-RN® items; there willbe between 75 and 265 items. The test ends when it is 95% certain yourability is↑or↓the passing standard.TIPS13%–19%8%–14%6%–12%6%–12%6%–12%13%–19%13%–19%11%–17%

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2■Answers may be selected or deleted several times if desired beforeconfirming a final answer. You must answer every question. You cannotreturn to a previous question.■A time-remaining clock is in the screen’s upper right-hand corner.■A calculator on the computer is available for calculations.Go to www.NCSBN.org to access an NCLEX tutorial to practice multiplechoice and alternate format items on the computer.Critical ThinkingDefinition, Influences, and Uses of Critical Thinking■Definition of critical thinking:Cognitive technique by which you reflect onand analyze your thoughts, actions, decisions■Intellectual standards that influence critical thinking:Focused, methodical,clear, deliberate, logical, relevant, accurate, precise■Processes that require critical thinking:Test taking, nursing process,problem solving, decision making, diagnostic reasoningMaximize Your Critical Thinking AbilitiesActionBenefitBe positive:Be optimistic■Maintain positive mentalattitude:Replace negativethoughts with positive onesBe calm:Control anxious feelings■Use relaxation techniques:Practice breathing exercises andguided imageryBe inquisitive:Question and investigate■Ask the questions how, why,what:e.g., How does Colacepromote a bowel movement? Whydoes BP drop with hemorrhage?Be persistent:Follow a course of action■Develop self-discipline:Belogical and organizedTIPS■↑Positive thinking and↓negativethinking that can interfere withlearning■↓Anxiety■↑Control in relation to intellectualtasks■↑Ability to determine significanceof information■↑Understanding/retention ofinformation■↑Ability to apply information■↑Control over variablesassociated with thinking

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3Maximize Your Critical Thinking Abilities(Continued)ActionBenefit■Develop perseverance:Adhereto a preset study schedule; remaindetermined■Maintain motivation:Set shortand long-term goals; divide tasksinto steps; reward selfBe creative:Be innovative and resourceful■Develop open-mindedness:Compartmentalize identifiedbeliefs, opinions, biases,stereotypes, prejudices■Develop comfort with ambiguity:Recognize that there is more than1 way to perform a task/achieve agoal■Develop independent thought:Consider all possibilities andarrive at an autonomousconclusion■Take risks:Implement uniqueinterventions within the definitionof nursing practice and safetyguidelinesBe reflective:Thoughtfully explore and assess■Develop courage:Confront difficulttasks (e.g., reviewing mistakes)with a non-judgmental attitude■Develop humility:Admit yourlimitations—defensive thinkingpromotes negativity, which closesthe mind■Use retrospective reviews:Recallinformation/event to rediscover/explore its meaning; conductinternally or with othersTIPS■↓Procrastination;↑enthusiasm■↑Efficiency of time management■↓Stress of making purposefuldaily study decisions: inspiresaction■↑Goal-directed behavior■↑Openness to differentperspectives;↓egocentricthinking;↑nonjudgmentalthinking/practice■↑Comprehension, synthesis,interpretation, analysis ofinformation: promotes practicebased on principles; innovation■↑Ability to synthesize, summarize,conceptualize: promotes practicebased on principles;↑innovation■Removes negative emotions fromthe task;↑positive thinking■Allows an open mind to exploreand acquire information; permitsnonjudgmental review ofmistakes■Identifies strengths, weaknesses,and gaps in knowledge;↑understanding of relationshipsbetween information and itsapplication;↓future mistakes

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4General Study Skills■Set goals■Take class notes■Manage your time■Control internal and external distractions■Establish a routine■Simulate a school environment■Prepare for class■Balance sacrifices and rewardsUse Techniques Appropriate for Learning DomainsActionBenefitCognitive domain (thinking):Knowing, comprehending, applying, analyzing,synthesizing, evaluating■Use all your senses■Use memorization techniques■Put information into own words■Apply information in newsituationsAffective domain (feeling):Receiving, valuing, organizing, characterizing■Observe role models■Explore feelings, beliefs, values■Integrate values into philosophyof lifePsychomotor domain (doing):Imitating, manipulating, developing precision,articulating, naturalizing■Observe others performing a skill■Manipulate equipment whiledoing procedures■Include speed/timing whenpracticing skills■Practice skills repeatedlyTIPS■↑Reception of information■↑Retention of basic information■↑Understanding■Encourages correct use ofinformation■↑Sensitivity■↑Self-disclosure/growth■↑Consistency in actions; allowsfor self-actualization■Identifies steps of a skill■Transfers information from headto hands■Promotes proficiency throughrepetition■Perfects the skill; naturalizationoccurs when skill becomesautomatic

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5Specific Study SkillsHow to Remember/Recall Information: Commit Facts to MemoryActionBenefitExampleMemorization:Repeatedlyreciting out loud,reviewing in your mind,writing it downAlphabet cues:Combination ofsignificant lettersAcronyms:Word formedfrom the first letters of aseries of factsMnemonics:A phrase,motto, verseTIPS■Repetition↑retention ofinformation■Each letter prompts recall ofspecific information■Each letter jolts retrieval ofspecific information■Prompts recall of specificinformation■Lists on index cards: Steps of aprocedure; signs of a specificelectrolyte imbalance■Flash cards: Drug classification onone side and action on reverse side;medical terminology on one side anddefinition on reverse side■The3 Ps:Cardinal signs of diabetesmellitus:■Polyuria: Increased secretion/excretion of urine■Polydipsia: Excessive thirst■Polyphagia: Eating excessiveamounts of food■RACE:Procedure for a fire in a healthcare facility■Rescue people in immediate danger■Activate the fire alarm■Confine the fire■Evacuate people to a safe area■“There are 15 grains of sugar in 1graham (gram) cracker.” This sentenceshould help you remember that 15grains are equivalent to 1 gram.

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6How to Understand Information: Translate, Interpret, and Determine Implications of InformationActionBenefitExampleExplore how or whyinformation is relevantand valuableStudy in small groupsHow to Manipulate Information: Apply, Solve, Modify, and Use InformationActionBenefitExampleRelate new information toprior learningRecognize commonalitiesTIPS■Significant information ismore likely remembered■Sharing/listening↑understanding andcorrects misinformation■Placing information withina personal frame ofreference makes informa-tion more meaningful■Application of informationto similar situations↑learning■Elevation of an extremity reducesperipheral edema■How:Hand held above elbow/shoulder↑venous return via gravity, which↓edema■Discussing differences between hyper- andhypoglycemia■Debating the pros and cons ofbreastfeeding■Identify more correct things the nurseshould do in addition to the correctanswer presented in a test question■Pathophysiology of diabetes should buildon normal physiology of the pancreas■Placing a pt in a left side–lying positionafter a liver biopsy should build on thefact that pressure compresses bloodvessels, which supports hemostasispreventing hemorrhage■Actions that use the principle of gravity:Enema instillation, elevation of extremityto limit edema, high Fowler’s position topromote respirations

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7How to Analyze Information: Examine the Organization, Structure, and Interrelationships of InformationActionBenefitExampleRecognize differencesPractice test takingReview rationales forall optionsModify test questionsAnalyze yourperformanceTIPS■↑Ability to analyze anddiscriminate significance ofinformation■Reinforces learning, buildsendurance,↑test-taking andtime-management skills,↑testing comfort■Reinforces concepts andprinciples,↑new learning,strengthens critical thinking,corrects misinformation■Identify commonalities anddifferences,↑opportunities forexploring content■Analysis identifies areas ofstrength, gaps in knowledge,information-processing errors,effectiveness of educatedguesses, plans for future study■Variety of causes that can↑BP:Hypervolemia, rigid arterial walls,emotional stress■Answer questions at the end of achapter■Take a simulated test in a NCLEX prepbook■Take a simulated NCLEX test on acomputer■Review why the correct answer iscorrect■Review why the incorrect options areincorrect; look up additionalinformation in textbooks■Change a key word in a stem tochange the focus: “Identify the ptadaptation associated with acute pain.”Change the wordacutetochronicandthen identify if any options apply■Identify number of questionsanswered correctly/incorrectly■Group questions answered incorrectlyby Knowledge Deficits and InformationProcessing Errors (see Tab 8)■Identify Personal Performance Trends(see Tab 8)■Design a plan for future test success

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8Test-Taking and Study TipsSee enclosed disk for 160 examples of questions demonstrating the 15 test-taking tips and alternate format questions.Identify positive polarity in a stem■Correct answer is in accord with a truth, fact, principle, or action thatshould be done; it attempts to determine if you can understand, apply, ordifferentiate correct information.✔Study Tip: Review content being tested; identify additional things thenurse should do.Identify negative polarity in a stem■Correct answer reflects something that is false; the wordsexcept,not, contraindicated, unacceptable, least, avoid, violate, untrue, sideeffect,andexceptionindicate negative polarity. If 3 answers appearcorrect, you may have missed the negative word in the stem.✔Study Tip: Change negative word to a positive word and then answerthe question.Identify words that set a priority■Correct answer is what should be donefirst; the wordsinitial, main,primary, initially, greatest, best, first, most,andpriorityrequire ranking ofoptions from most to least desirable. If unable to identify correct answer,eliminate least desirable option and repeat again until left with a finaloption.✔Study Tip: After selecting correct answer, select what action should bedone next.Identify opposites in options■When 2 options reflect extremes on a continuum, frequently 1 of them isthe correct answer; opposites may be obvious or obscure.✔Study Tip: Examples of opposites: hypo- vs. hyper-; increase vs.decrease; brady- vs. tachy-; identify what is associated with the incorrectopposite (e.g., tachycardia is associated with hyperthyroidism vs.bradycardia being associated with hypothyroidism).Identify key words in a stem■Identify important word or phrase that modifies another word (e.g., earlyvs. late sign of shock).✔Study Tip: Change key words in stem; this changes focus of questionand↑opportunities for learning.TIPS

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9Identify patient-centered options■Correct answers testing principles in the affective domain focus onfeelings, choices, empowerment, and preferences.✔Study Tip: Examples of pt-centered options: Acknowledging: “Losingyour independence must be difficult?” Offering a choice: “Would youlike your bath at 7 or 10 today?” Empowering: Encourage pt to writedown questions for the physician. Determining preferences: “Whatfoods do you like to eat?”Identify equally plausible options■When 2 options are similar and 1 is not better than the other, generallyboth are incorrect.✔Study Tip: Identify other equally plausible facts related to either the 3incorrect options or the correct answer.Identify options with “absolute” terms■The wordsall, just, none, only, never, every,andalwayshave noexceptions; 1 of these before a statement that is true generally makesit an incorrect option. Options with absolute terms are more oftenincorrect.✔Study Tip: Examples of options to be eliminated:Alwaysposition aninfant prone andjustprescription drugs can cause interactions;exceptions include:Alwaysmaintaining an airway and focusing onthe pt.Identify the global option■A global option is a broad general statement, whereas the 3 other optionsare specific and inherently are included under the mantel of the globaloption.✔Study Tip: What else can be included under the global option?Identify options that deny a patient’s feelings, needs, concerns■Options that deny feelings, give false reassurance, focus on nurse,encourage cheerfulness, or change the subject cut off communication andshould be eliminated.✔Study Tip: Examples of options to be eliminated:Denies feelings:“Don’tcry. It is not so bad.”False reassurance:“You’ll feel better tomorrow.”Focuses on the nurse:“The thought of dying would frighten me.”Cheerfulness: “Cheer up. You are getting better.”Identify the unique option■When 3 options are similar in some way and 1 is different, the uniqueoption often is the correct answer (e.g., 3 options promote a bowelmovement and correct answer causes diarrhea).TIPS

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10✔Study Tip: Identify additional similar or different examples of correctand incorrect options.Identify clues in a stem■A word(s) in the stem that is identical, similar, paraphrased, or closelyrelated to a word(s) in an option is called aclang; a clang can beobvious or obscure. Generally, an option with a clang is the correctanswer.✔Study Tip: Identify a similar word(s) that relates to an important word inthe stem (e.g., to the wordmovementin a stem consider similar wordssuch asactivityandmobilitythat may be found in an option).Identify duplicate facts in options■If 2 or more facts are in each option and identical or similar facts are in atleast 2 of the 4 options, and you can identify at least 1 fact that is corrector incorrect, you can eliminate at least 2 options.✔Study Tip: Identify additional facts that may be correct.Use Maslow to identify correct option■Answer the question in light of Maslow’s hierarchy of needs; basicphysiologic needs are 1st-level needs that are a priority and are followedby needs associated with safety and security (2nd), love and belonging(3rd), self-esteem (4th), and self-actualization (5th).✔Study Tip: Identify an intervention associated with each level ofMaslow’s hierarchy of needs in relation to the question.Use multiple test-taking tips■First analyze the stem for 1 or more test-taking tips. Then analyze theoptions for 1 or more test-taking tips. When you focus on what the stem isasking and eliminate options from consideration, you maximize the abilityto select the correct answer.✔Study Tip: Practice answering questions at the end of a chapter or intest-taking books using the presented test-taking tips.Alternate Format Questions and Test-Taking TipsAlternate format questions evaluate certain knowledge more effectively thanthe typical multiple-choice question. They supplement multiple-choicequestions, which remain the majority of questions. Any format, including thestandard multiple-choice question, may include a chart, table, or graphicimage. Alternate format questions are scored as either right or wrong, andpartial credit is not given.TIPS

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11Ordered response (drag and drop) question■Presents a scenario or makes a statement and then lists a variety ofactions or factors that must be placed in sequence or in order of priority.The sequence chosen must be identical to the correct sequence to receivecredit.✔Test-Taking Tip: Identify the action/factor you believe should be first.Identify the action/factor you believe should be last. Evaluate theremaining 2 actions/factors and make a final determination as to whichone goes second. The remaining action/factor is placed third.Fill-in-the-blank (calculation) question■Requires manipulation, interpretations, or solving a problem based onpresented information. It requires an intellectual skill such as computinga drug dosage, calculating an I&O, or determining the amount of IVsolution to be given. The recorded answer must be identical to thecorrect answer to receive credit. You do not have to type in the unit ofmeasurement.✔Test-Taking Tip: Before attempting to answer the question, recallinformation related to the question (e.g., memorized equivalents,formulas); this taps your knowledge first and limits confusion.Multiple-response question■Asks a question and then lists several responses. You must identify the 1or more responses that are correct. All correct responses must be selectedto receive credit.✔Test-Taking Tip: Before looking at presented options, quickly reviewinformation you know about the topic. This taps your knowledge firstand limits confusion after looking at presented options. Compare yourlist to presented options. Some of your recalled information shouldmatch. Then review the remaining presented options and determine ifthey are applicable. If you look at the presented options first, eliminateat least 1 or 2 you believe are wrong. Then identify at least 1 or 2 youbelieve are correct. Finally, evaluate the remaining options and make adetermination if they are correct or not.Hot-spot question■Asks a question in relation to a graphic image, picture, chart, or table. Youmust identify a location or analyze information on the illustration toanswer the question. Your answer must mirror the correct answer exactlyto receive credit.✔Test-Taking Tip: Read the question carefully to identify exactly what thequestion is asking. This limits misinterpretation and confusion. Whenquestions reflect anatomy and physiology, close your eyes, visualize thearea, briefly recall the significant structures and functions, and then lookTIPS

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12at the picture. When questions involve graphs or tables, first break theminto segments for analysis and then review them as a whole.Chart/exhibit question■Presents a problem and then provides a chart/exhibit that has severaltabs. Each tab has to be clicked to retrieve information contained withinthe tab. The data must be analyzed and the significant informationgleaned from the material presented to answer the question or eliminateincorrect options. These questions require the highest level of criticalthinking (analysis and synthesis).✔Test-Taking Tip: First identify what the question is asking, then click eachtab to collect data. Dissect, analyze, and compare and contrast theinformation collected in light of what the question is asking. Extensiveinformation must be recalled from your body of knowledge andcompared to the information in context of the situation presentedin the question.TIPS

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13BASICSChild:1year–adolescentTap and ask, “Are you OK?”Carotid or femoralCenter of chest, between nipples1 hand:Heel of 1 hand2 hands:Heel of 1 hand and heel ofsecond hand on topWitnessed collapse with no response; unwitnessed event after 5 cycles of CPRPlace on hard surface; head tilt-chin lift (lift-jaw thrust with spinal trauma);look, listen, feel for air; if not breathing, give 2 breaths; cover nose andmouth of infant when rescue breathingInfant:1yrNo response to verbal or tactile stimuliBrachial or femoralCenter of chest below nipples1 rescuer:2 fingers2 rescuers:2 thumb-encircling handsRate:Approximately 100/minDepth:Approximately1/3to1/2depth of chest1 rescuer—30:2;2 rescuers—15:2Sudden collapse:ASAPAll others:After 5 cycles of CPRNo recommendation for infants1yrPulse with no breaths:60/min:12 to 20 breaths/min;60/min:continue CPRCardiopulmonary Resuscitation (CPR)—Child and InfantManeuverAssess for responseActivate 9111 rescuerAirway breathsPulse checkCompression landmarksCompression method:“Hard and fast” withchest recoilCompression rate anddepthComp/vent ratioDefibrillationRescue breathing

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14Ethical and Legal FoundationsBasis of Ethical Decision Making■Autonomy:Support personal freedom and decision making■Beneficence:Promote good■Fidelity:Keep promises and commitments■Justice:Treat people fairly and equally■Nonmaleficence:Do no harm■Paternalism:Make or allow a person to make a decision foranother■Respect:Acknowledge rights of others■Veracity:Tell the truthLegal Terms■Advance directive:Written document that addresses treatment desires inthe future if unable to make decisions■Living will:Specifically identifies treatment desires■Health care proxy(durable power of attorney): Assigns decision makingto another■Do not resuscitate:Order stating that a patient should notbe revived; at request of patient when able; health care proxy,family member, or legal guardian when patient is unable to giveconsent■Assault:Threat of unlawful touching of another■Battery:Unlawful touching of another without consent (e.g., proceduresperformed without consent)■False imprisonment:Restriction/retention of patient without consent; userestraints in compliance with policy and procedure; have patient signrelease if desiring to leave facility against medical advice■Good Samaritan Law:Legal protection for those who render care in anemergency without expectation of remuneration■Libel:Written statement causing harm to patientBASICS

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15■Malpractice:Professional negligence; occurs when the nurse owed a dutyto the patient, the nurse did not carry out that duty, and it resultedin injury to the patient■Negligence:Failing to perform an act that a reasonable prudent nursewould do under similar circumstances; may be an act of omission orcommission. Examples: Failure to ensure patient safety (falls); improperperformance of a treatment (burns from warm soak); med errors;inappropriate use of equipment (excessive IVF via pump); and failureto monitor, report, or document patient’s status■Organ donation:Donor card, living will, or family consent if patientis unable to participate in decision is necessary to donate organs■Respondeat superior:Latin term meaning “let the master answer”;employer is responsible for acts of employee causing harm duringemployment activities■Slander:Oral statement resulting in damage to patient; nurse incorrectlytells others that patient has AIDS and it affects patient’s business■Uniform Determination of Death Act:■Cardiopulmonary criteria:Irreversible cessation of circulatory andrespiratory function■Whole-brain criteria:Irreversible cessation of all functions of the entirebrain and brain stem (organs may be healthy for donation even thoughmeeting whole-brain criteria)Disease and Treatment MnemonicsCAUTION: EARLY SIGNS OF CANCERINFECT: S&S OF INFECTIONChange in bowel or bladder habitsAsore throat that doesn’t healUnusual bleeding or dischargeThickening or lumpIndigestion; dysphagiaObvious change in a wart or moleNagging cough ot hoarsenessRICE: TREATMENT FORACUTE INJURYRest;↓stress/strain on injuryIce; vasoconstriction↓edema and painCompression; external pressureElevate: gravity↓edemaBASICSIncreased pulse, respirations, WBCsNodes are enlargedFunction is impairedErythema, Edema, ExudateComplains of discomfort/painTemperature – local or systemic

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16Therapeutic Nurse-Patient RelationshipPhases of InteractionPhaseNursePatientPreinteraction:Begins beforecontact with patientOrientation(introductory):Begins at firstmeeting ofnurse/patientWorking:Beginswhen patientidentifies problemsto be worked onResolution(termination):Begins whenproblems areresolved; endswhen relationshipis terminatedBASICSExplore personal feelings, values, attitudesCollect data about patientPlan for 1st interactionListen; be empatheticIdentify boundaries of relationship(termination begins here)Clarify expectationsEstablish rapportAssist with exploration of issuesSupport healthy problem solvingAssist with strategy developmentIdentify own reactions to client based onown needs, conflicts, relationships(counter transference)Review objectives/goals achievedReinforce adaptive behaviorsShare feelings about terminationAvoid discussing previous issuesEncourage independence; focus on futurePromote positive family interactionsRefer to community resourcesPatient has no role in this phaseRecognize need for helpCommit to a therapeuticrelationshipBegin to test relationshipDevelop trust in nurseExamine personal issuesDevelop strategies to resolve issuesMay superimpose feelings fromanother relationship onto thenurse/patient relationship(transference)Share feelings about termination(anger, rejection, regression;negative feelings may beexpressed to deal with loss)May attempt to discuss previousissuesAssume responsibility for use ofcommunity resources

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17BASICSInterviewingInterviewing Skills■Active listening:Absorbs content/feelings; uses all senses; includesverbal/nonverbal attending, appropriate gestures (head nodding), eyecontact, sitting, open posture, vocal cues (“mmm”).■Clarification:Asks for more information. Checks accuracy.↓Ambiguity: “Iam not sure I know what you mean by that.”■Confrontation:Presents reality, identifies inconsistencies.↑Self-awareness. Use gently after trust is developed. Pt: “I never haveany visitors.” Nurse: “I was here yesterday when you had 3visitors.”■Direct:Collects specific information quickly: “Where is your pain?”■Focusing:Let patient finish thoughts. Centers on key elements to↓rambling. “When talking about your house, you mentioned scatter rugs.Let’s talk more about being safe in your home.”■Nonverbal:Promotes verbalization. Techniques include leaning forward,nodding head, smiling, gestures.■Open-ended:Invites elaboration, nonthreatening. Avoids yes/no answer:“Tell me about what a typical day is like for you.”■Paraphrasing:Restates message in same/similar words. Focuses oncontent; encourages discussion. Pt: “I may not make it through thesurgery.” Nurse: “You think you are going to die?”■Reflection:Describes/interprets feelings/mood: “You sound upset.”■Silence:Allows for reflection, processing a response. Prompts talking.Useful when patient is sad/grieving or remaining quiet.■Summarizing:Reviews key elements; brings closure. Clarifiesexpectations: “Today we talked about . . .”■Touch:Conveys caring, is reassuring. May invade personal space; avoidwith suspicious or angry patients. Hold patient’s hand, patting gently onpatient’s shoulder.■Validation:Confirms what the nurse heard or observed: “I understand thatyou just said . . .”Barriers to Communication■Pain■Failing to listen■Overly optimistic statements (false reassurance)■Advising■Changing topic■Judgmental or minimizing comments

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18■Challenging, defensive, or disapproving responses■Direct probing and “how” and “why” questions■Interruptions, environmental noise, or extremes in temperature■Trite, common expressions (clichés)LeadershipLeadership and Management Terms■Accountability:Answerable for actions/judgments regarding care■Autonomy:Nurse can make independent decision to decide/act■Case management:Coordination of interdisciplinary care for pt■Decentralized management:Staff participate in decision making■Performance appraisal:Evaluation of a nurse’s compliance (quality& quantity) with standards and roles within job description■Professional standards:Actions consistent with minimum safeprofessional conduct. Description of responsibilities. ANA, JCAHO, agencypolicy and procedure■Quality improvement:Activities to↑achievement of ideal care■Responsibility:Duties and activities that nurse is hired to performLeadership Styles■Autocratic:Complete control over decisions, goals, plan, and evaluation ofoutcomes; firm, insistent; often used in emergencies or when staff isinexperienced or new■Democratic:Participative; shares responsibilities; uses role to motivatestaff to achieve communal goals (shared governance), encouragesintercommunication and contributions; used to help staff grow in abilities;↑motivation,↑staff satisfaction■Laissez-faire:Nondirective; relinquishes control & direction to staff; bestused with experienced, expert, mature staff who know rolesTasks That May Not Be Delegated to Unlicensed Nursing Personnel■Assessing, analyzing, and interpreting data■Identifying nursing diagnoses■Formulating a plan of care■Evaluating pt responses to nursing care and extent of outcomeachievement■Screening and classifying pts to determine priority to receive intervention(triage)BASICS

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19■Giving/monitoring parenteral medications■Performing patient teaching■Performing professional procedures (e.g., sterile irrigations, insertionof urinary catheter, colostomy irrigation, tracheal suctioning)Leader and/or Manager QualitiesEffective leaders and managers need to:■Understand human behaviorHave insight into its relationship to beliefs, values, feelings; be sensitiveto others’ feelings and problems■Use effective communication skillsBe clear, concise, avoid ambiguity; use appropriate format (verbal,written, formal, informal); be aware of own nonverbal behavior; supportstaff in growth of skills■Use power appropriatelyPower attained through place in table of organization (positional); powerattained through knowledge and experience or perceived by staff(professional); do not abuse■Respond to staff needsListen attentively, attend to needs, provide positive feedback, avoidfavoritism, set realistic expectations, avoid mixed messages, and treatstaff with respect: Counsel privately; keep promises; avoid threats,superior attitude, criticism, or aggressive confrontation■Delegate appropriatelyRight person(competent subordinate),right task(is within scope ofpractice),right situation(nursing assistant should not perform a routinetask on an acutely ill patient),right communication(clear instructions,validate understanding of instructions),right supervision(monitor actions,evaluate outcomes, review with subordinate); leader retains accountability■Provide opportunities for personal growthAid less experienced nurse to↑knowledge, experience, responsibility(e.g., mentor/preceptor, continuing education, staff education)■Use critical thinking and problem solvingProcess requires effective communication, assessment, planning, andparticipation of staff and evaluation of outcomes■Recognize conditions that are conducive to changeNeed is recognized by all staff and all have a stake in outcome; includeall creatively in the process; focus on benefits; provide positive feedback;offer incentives■Process follows problem-solving processBASICS

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20■Change is planned and introduced gradually■Change is initiated in a calm rather than chaotic atmosphere; best aftera prior successful change■Resistance is recognized and addressed; causes of resistance: change isthreatening; lack of understanding; disagreeing with purpose/approach,beliefs, and values;↑in responsibility; habit; fear of failureLevels of Management■First-level:Supervises nonmanagerial staff; oversees day-to-day activitiesof a group (e.g., Team Leader, Charge Nurse)■Middle-level:Supervises a group of first-level managers (e.g., Supervisor,Coordinator, Head Nurse)■Upper-level:Organizational executives; sets goals and strategic planning(e.g., VP for Nursing, Associate Director of Nursing)Staff Nurse Role■Function as role model regarding professional conduct■Receive report from nurse previously responsible for patient■Make rounds on all pts immediately after receiving report■Set priorities regarding pt needs: Immediate threat to survival (problemswith breathing, VS,↓LOC), requests for help (pain, toileting), urgent butnot immediate needs (teaching)■Coordinate and/or perform care for assigned pts; use time-managementskills; complete all care assigned■Delegate care to subordinates that is within their job description■Monitor care delegated; establish clear expectations; encouragecommunication; evaluate patient outcomes related to delegated tasks(nurse retains accountability for delegated tasks)■Give report to next nurse responsible for patient■Engage in quality improvement (QI) activities■Participate in intradepartmental and interdepartmental meetingsNurse Manager Role■Function as a role model regarding professional conduct■Set standards of performance; establish goals for the unit with the staff;mobilize staff and agency resources to attain goals■Support mutual trust; treat staff with respect; counsel privately■Empower staff: Support innovation, seek staff members’ opinions,promote professional environment and growth, reward growth■Perform pt rounds with multidisciplinary teamBASICS

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21■Monitor nursing practice and achievement of standards■Design and implement a quality improvement (QI) program for the unit;engage staff in QI activities■Assist in staff development plan and orientation of new employees■Schedule staffing for the unit■Conduct regular staff meetings with all shifts■Evaluate performance of subordinates (performance appraisal)■Participate in intradepartmental and interdepartmental meetingsCommunity Nursing■Community health nursing (public health nursing):Nursing care for aspecific population living in the same geographic area, or groups havingsimilar values, interests, and needs. Aims to develop a healthyenvironment in which to live■Public health functions:Community assessment, policy development,and facilitating access to resources. Cohesiveness is promoted byengaging community members in the problem-solving process andpromoting empowerment through education, opportunities, andresources. Successful public health programs are congruent with thatof the interests and goals of the community■Assessment of a community:■Structure (milieu):Geographical area, environment, housing, economy,water, and sanitation■Population:Age and sex distribution, density, growth trends,educational level, cultures and subcultures, religious groups■Social systems:Education, communication, transportation, wel-fare, and health care delivery systems; government and volunteeragencies■Community-based nursing:Nursing care delivered in the communitywhile focused on a specific individual’s or family’s health care needs. Theindividual is viewed within the larger systems of family, community,culture, and society■Vulnerable populations:People at risk for illness (e.g., homeless, living inpoverty, migrant workers, living in rural communities, pregnantadolescents, suicidal individuals, frail older adults)■Stigmatized groups:People viewed with disdain/disgrace (e.g., pts with dxof HIV positive, substance abuse, mental illness)■Settings in which nurses work:Homes, community health centers, clinics,industry, rehabilitation centers, schools, crisis intervention centers (phonelines), shelters, halfway houses, sheltered workshops, day care centers,forensic settingsBASICS

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22■Roles of nurses:Discharge planner, case manager, counselor, andepidemiologist, health promoter, case finder, caregiver, educator,researcher, consultant, advocate, role model, change agent■Hospice care:Palliative (relieve or↓discomfort) and supportive care fordying persons and their caregivers. Experts in pain and symptommanagement. Focuses on preserving dignity and quality over quantity oflife. Supports bereavement; usually during last 6mo of life■Respite care:Temporary care for homebound so that caregivers have relieffrom day-to-day responsibilitiesPatient EducationLearning DomainsCognitive domain:Thinking, acquiring, comprehending, synthesizing,evaluating, storing, and recalling information.■Build on what pt knows. Present essential information first. Addinformation as pt asks questions.■Teaching strategies: Lecture, discussion, audiovisuals, printed material,computer-assisted and Web-based instruction.■Evaluation: Assess knowledge by verbal/written means.Affective domain:Addresses attitudes, feelings, beliefs, values. Takes time tointernalize need-to-change behavior.■Understand own value system. Respect uniqueness of each pt. Help ptexplore feelings.■Teaching strategies: Discussion, play, role modeling, panel discussion,groups, role-playing.■Evaluation: Evidence of behavior incorporated into lifestyle.Psychomotor domain:Addresses physical/motor skills. Requires dexterityand coordination to manipulate equipment. Ultimately performs a task withskill.■Achieve mastery of each step before moving on to next step.■Teaching strategies: Audiovisuals, pictures, demonstrations, models.■Evaluation: observation of performance of skill (return demonstration).Teaching and Learning—General Concepts■Education can prevent illness, promote or restore health,↓complications,↑independence and coping,↑individual and family growth. Incorporatethroughout health care delivery.■Environment should be conducive to learning: Private, quiet, well lit,comfortable, and lack distractions (close door/curtain, shut off TV).■Teaching process should follow format of Nursing Process.BASICS

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