HESI NCLEX Review Exam 2022

HESI NCLEX Review Exam 2022 Maslow's Hierarchy of Needs - - Physiologic • Safety • Love and Belonging • Esteem • Self-actualization Nursing Process - - Assessment • Diagnosis (Analysis) • Planning • Implementat ...

HESI NCLEX Review Exam 2022 Maslow's Hierarchy of Needs - - Physiologic • Safety • Love and Belonging • Esteem • Self-actualization Nursing Process - - Assessment • Diagnosis (Analysis) • Planning • Implementation (treatment) • Evaluation ABCs - - • Airway • Breathing • Circulation Hgb - - 12-18 Hct - - 37-52 RBCs - - 4.2-6.1 WBCs - - 4.5-11K Platelets - - 150-400K BUN - - 10-20 Creatinine - - 0.5-1.2 Glucose - - 70-110 Cholesterol - - <200 Billirubin Newborn - - 1-12 Na+ - - 136-145 K+ - - 3.5-5 HypoK+ - - Prominent U waves, Depressed ST segment, Flat T waves HyperK+ - - Tall T-Waves, Prolonged PR interval, wide QRS Ca+ - - 9-10.5 Hypocalcemia - - muscle spasms, convulsions, cramps/tetany, + Trousseau's, + Chvostek's, prolonged ST interval, prolonged QT segment Mg+ - - 1.5-2.5 Cl- - - 96-106 Phos - - 3-4.5 Albumin - - 3.5-5 Spec Gravity - - 1.005-1.030 Hgb A1c - - 4-6% ideal, < 7.5% = OK (120 days) Lithium - - 0.5-1.5 pH - - 7.35-7.45 CO2 - - 35-45 (Respiratory driver) ... High = Acidosis HCO3 - - 21-28 (Metabolic driver) ... High = Alkalosis Antidote Digoxin - - Digiband Antidote Coumadin - - Vitamin K Antidote Benzo - - Flumzaemil AntidoteMag Sulfate - - Calcium gluconate Antidote Heparin - - Protamine Sulfate Antidote Tylenol - - Mucomist Antidote Opiates - - Narcan Antidote cholinergic meds - - Atropine Rifampin (for TB) - - Rust/orange/red urine and body fluids Pyridium (for bladder infection) - - Orange/red/pink urine Glasgow Coma Scale - - <8 = coma Diabetic Coma vs. Insulin Shock - - Give glucose first - If no help, give insulin Fruity Breath - - Diabetic Ketoacidosis Acidosis - - If it comes out of your ass Alkalosis - - Vomiting Lipitor (statins) - - No grapefruit juice Hold Digoxin - - HR <60 ACE Inhibitor dose - - Stay in bed for 3 hours Pulmonary air embolism prevention - - Trendelenburg (HOB down) + on left side (to trap air in right side of heart) Head Trauma and Seizures - - Maintain airway = primary concern Peptic Ulcers - - Feed a Duodenal Ulcer (pain relieved by food) ... Starve a gastric ulcer Acute Pancreatitis - - Fetal position, Bluish discoloration of flanks (Turner's Sign), Bluish discoloration of pericumbelical region (Cullen's Sign), Board like abdomen with guarding ... Self digestion of pancreas by trypsin Hold tube feeding if - - residual > 100mL Gullain-Barre Syndrome - - Weakness progresses from legs upward - Resp arrest Trough draw - - ~30 min before scheduled administration Peak Draw - - 30-60 min after drug administration. Most suicides occur - - after beginning of improvement with increase in energy levels MAOIs - - Hypertensive Crisis with Tyramine foods Nardil, Marplan, Parnate Need 2 wk gap from SSRIs and TCAs to admin MAOIs Phenothiazines - - (typical antipsychotics) - EPS, Photosensitivity Atypical Antipsychotics - - work on positive and negative symptoms, less EPS Benzos (Ativan, Lorazepam, etc) - - good for Alcohol withdrawal and Status Epilepticus Alcohol Withdrawal - - Delerium Tremens - Tachycardia, tachypnea, anxiety, nausea, shakes, hallucinations, paranoia ... (DTs start 12-36 hrs after last drink) Opiate (Heroin, Morphine, etc.) Withdrawal - - Watery eyes, runny nose, dilated pupils, NVD, cramps Stimulants Withdrawal - - Depression, fatigue, anxiety, disturbed sleep Hypoventilation - - Acidosis (too much CO2) Hyperventilation - - Alkalosis (low CO2) No BP or IV on side of Mastectomy - - No BP or IV on side of Mastectomy Pinpoint Pupils - - Opiate OD Lesions of Midbrain - - Decerebrate Posturing (Extended elbows, head arched back) Lesions of Cortex - - Decorticate Posturing (Flexion of elbows, wrists, fingers, straight legs, mummy position) Urine Output of 30 mL/hr - - minimal competency of heart and kidney function Renal Failure - - Restrict protein intake Usually 3 phases (Oligouric, Diuretic, Recovery) Monitor Body Wt and I&Os Fluid and electrolyte problems - - Watch for HyperK+ (dizzy, wk, nausea, cramps, arhythmias) Pre-renal Problem - - Interference with renal perfusion Intra-renal Problem - - Damage to renal parenchyma Post-renal Problem - - Obstruction in UT anywhere from tubules to urethral meatus. Steroid Effects - - Moon face, hyperglycemia, acne, hirsutism, buffalo hump, mood swings, weight gain - Spindle shape, osteoporosis, adrenal suppression (delayed growth in kids) . . . (Cushing's Syndrome symptoms) Addison's' Crisis - - medical emergency (vascular collapse, hypoglycemia, tachycardia ... Admin IV glucose + corticosteroids) ... No PO corticosteroids on empty stomach Potassium sparing diuretic - - Aldactone (Spironolactone) ... Watch for hyperK+ with this and ACE Inhibitors. Cardiac Enzymes - - roponin (1 hr), CKMB (2-4 hr), Myoglobin (1-4 hr), LDH1 (12-24 hr) MI Tx - - Nitro - Yes ... NO Digoxin, Betablockers, Atropine Fibrinolytics - - Streptokinase, Tenecteplase (TNKase) BPH Tx - - TURP (Transurethral Resection of Prostate) ... some blood for 4 days, and burning for 7 days post-TURP. Bladder Irrigation - - Only isotonic sterile saline Post Thyroidectomy - - Keep tracheostomy set by the bed with O2, suction and Calcium gluconate Pericarditis - - Pericardial Friction Rub, Pain relieved by leaning forward If a chest-tube becomes disconnected - - do not clamp ... Put end in sterile water Chest Tube drainage system - - should show bubbling and water level fluctuations (tidaling with breathing) TB - - Treatment with multidrug regimen for 9 months ... Rifampin reduces effectiveness of OCs and turns pee orange ... Isoniazide (INH) increases Dilantin blood levels Use bronchodilators before steroids for asthma - - Exhale completely, Inhale deeply, Hold breath for 10 seconds Suctioning - - Pre and Post oxygenate with 100% O2 ... No more than 3 passes ... No longer than 15 seconds ... Suction on withdrawal with rotation COPD: - - • Emphysema = Pink Puffer • Chronic Bronchitis = Blue Bloater (Cyanosis, Rt sided heart failure = bloating/edema) O2 Administration - - • Never more than 6L/min by cannula • Must humidify with more than 4L/hr • No more than 2L/min with COPD ... (CO2 Narcosis) • In ascending order of delivery potency: Nasal Cannula, Simple Face Mask, Nonrebreather Mask, Partial Rebreather Mask, Venturi Mask • Restlessness and Irritability = Early signs of cerebral hypoxia IVs and Blood Product Administration - - Vitals and Breath Sounds ... before, during and after infusion (15 min after start, then 30 min later, then hourly up to 1 hr after) IVs and Blood Product Administration Check Blood - - Exp Date, clots, color, air bubbles, leaks Blood Product Administration If transfusion rxn - - Stop and KVO with NS o Pre-medicate with Benadryl prn for previous urticaria rxns Isotonic Solutions - - • D5W • NS (0.9% NaCl) • Ringers Lactate • NS only with blood products and Dilantin Diabetes and Insulin o When in doubt - - Treat for Hypoglycemia first Hypoglycemia - - confusion, HA, irritable, nausea, sweating, tremors, hunger, slurring Hyperglycemia - - weakness, syncope, polydipsia, polyuria, blurred vision, fruity breath Draw Regular - - (Clear) insulin into syringe first when mixing insulins Rapid Acting Insulins - - Lispro (Humalog) and Aspart (Novolog) ... O: 5-15 min, P: .75-1.5 hrs Short Acting Insulin - - Regular (human) ... O: 30-60 min, P: 2-3 hrs (IV Okay) Intermediate Acting Insulin - - Isophane Insulin (NPH) ... O: 1-2 hrs, P: 6-12 hrs Long Acting Insulin - - Insulin Glargine (Lantus) ... O: 1.1 hr, P: 14-20 hrs (Don't Mix) Oral Hypoglycemics decrease glucose levels by - - stimulating insulin production by beta cells of pancreas, increasing insulin sensitivity and decreasing hepatic glucose production • Glyburide, Metformin (Glucophage), Avandia, Actos • Acarbose blunts sugar levels after meals Syphilis (Treponema pallidum) - - Chancre + red painless lesion (Primary Stage, 90 days) ... Secondary Stage (up to 6 mo) = Rash on palms and soles + Flu-like symptoms ... Tertiary Stage = Neurologic and Cardiac destruction (10-30 yrs) ... Treated with Penicillin G IM. Call Dr. post op if - - < 30 mL/hr urine, Sys BP < 90, T > 100 or < 96 Enema positioning - - Left Sims (flow into sigmoid) Liver Biopsy positioning - - Right side with pillow/towel against puncture site Cardiac Catheterization positioning - - Flat (HOB no more than 30 degrees), Leg straight 4-6 hrs, bed rest 6-12 hrs Amputation positioning - - Supine, elevate stump for 48 hrs Post Op Breathing Exercises - - Every 2 hours • Sit up straight • Breath in deeply thru nose and out slowly thru pursed lips • Hold last breath 3 seconds • Then cough 3 times (unless abd wound - reinforce/splint if cough) Watch for Stridor after any neck/throat Sx - - Watch for Stridor after any neck/throat Sx If chest tube comes disconnected - - put free end in container of sterile water Removing Chest Tube - - Valsalvas, or Deep breath and hold NG Tube Length - - End of nose, to era lobe, to xyphoid (~22-26 inches) A-fib and A-flutter = - - thrombus formation Left Hemisphere Lesion - - aphasia, agraphia, slow, cautious, anxious, memory okay Right Hemisphere Lesion - - can't recognize faces, loss of depth perception, impulsive behavior, confabulates, poor judgment, constantly smiles, denies illness, loss of tonal hearing Head Injuries - - Even subtle changes in mood, behavior, restlessness, irritability, confusion may indicate increased ICP • Change in level of responsiveness = Most important indicator of increased ICP • Watch for CSF leaks from nose or ears - Leakage can lead to meningitis and mask intracranial injury since usual increased ICP symps may be absent. Spinal Cord Injuries - - • Respiratory status paramount ... C3-C5 innervates diaphragm • 1 wk to know ultimate prognosis • Spinal Shock = Complete loss of all reflex, motor, sensory and autonomic activity below the lesion = Medical emergency • Permanent paralysis if spinal cord in compressed for 12-24 hrs • Hypotension and Bradycardia with any injury above T6 • Bladder Infection = Common cause of death (try to keep urine acidic) Burns - - • Infection = Primary concern • HyperK+ due to cell damage and release of intracellular K+ • Give meds before dressing changes - Painful • Massive volumes of IV fluid given, due to fluid shift to interstitial spaces and resultant shock Fractures - - Report abnormal assessment findings promptly ... Compartment Syndrome may occur = Permanent damage to nerves and vessels Pain, Pallor, Pulse, Paresthesia, Paralysis ELISA and Western Blot - - HIV Chvostek's Sign - - (Facial spasm after facial nerve tap) ... Hypocalcemia (hypoparathyroidism) Bloody Diarrhea = - - Ulcerative Colitis = Pyloric Stenosis - - Olive-Shaped Mass (epigastric) and Projectile Vomiting = Intussiception - - Current Jelly Stool (blood and mucus) and Sausage-Shaped Mass in RUQ Butterfly Rash = - - Systemic Lupus Erythemastosus CONTINUES...