NCLEX-RN Exam Review Key Points
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Questions and Answers

What are the symptoms of fluid volume excess? (Select all that apply)

  • Flushing
  • Elevated BP (correct)
  • Peripheral Edema (correct)
  • Dyspnea (correct)

    • What may be some lab findings related to fluid volume excess?

    Everything will be decreased including BUN, Hgb/Hct, serum osmolality, urine specific gravity and electrolytes.

    How would you treat fluid volume excess?

    Give diuretics (Lasix), fluid restrictions, weigh daily, monitor K+.

    What can cause a fluid volume deficit?

    <p>Inadequate fluid intake, hemorrhage, vomiting, or diarrhea.</p> Signup and view all the answers

    What are some symptoms of fluid volume deficit?

    <p>Weight loss, oliguria, and postural hypotension.</p> Signup and view all the answers

    What lab findings may be present with a fluid volume deficit?

    <p>Increased BUN, increased or normal creatinine, increased H/H, increased urine specific gravity.</p> Signup and view all the answers

    How do you treat fluid volume deficits?

    <p>Strict I&amp;O, replace with isotonic fluids, monitor BP, weight daily.</p> Signup and view all the answers

    What is most important to remember about intracellular electrolyte balance?

    <p>Potassium (K+) maintains osmotic pressure and imbalances may be life threatening.</p> Signup and view all the answers

    What is most important to remember about extracellular electrolyte balance?

    <p>Sodium (Na+) maintains osmotic pressure; fluid shifts according to concentration gradients.</p> Signup and view all the answers

    What is hyponatremia and how should you treat it?

    <p>Hyponatremia is a sodium level less than 135 mEq/L; treat by checking BP often and restricting fluids.</p> Signup and view all the answers

    What is hypernatremia and how should you treat it?

    <p>Hypernatremia is Na+ greater than 145 mEq/L; treatment includes restricting sodium diet and weighing daily.</p> Signup and view all the answers

    What is important to remember about hypokalemia?

    <p>Hypokalemia is a K+ level less than 3.5 mEq/L and may cause a rapid, thready pulse.</p> Signup and view all the answers

    What is hyperkalemia and how do you treat it?

    <p>Hyperkalemia is a K+ level greater than 5 mEq/L; treatment may include glucose with insulin and Kayexalate.</p> Signup and view all the answers

    What is hypocalcemia and how will you treat it?

    <p>Hypocalcemia is a Ca2+ level less than 8.5 mEq/L; treatment includes calcium supplements and vitamin D.</p> Signup and view all the answers

    How do you test for the Chvostek sign?

    <p>Tap on the face at a point just anterior to the ear and just below the zygomatic bone.</p> Signup and view all the answers

    How do you test for the Trousseau's sign?

    <p>Inflate a sphygmomanometer cuff above systolic blood pressure for several minutes.</p> Signup and view all the answers

    What is hypercalcemia and how do you treat it?

    <p>Hypercalcemia is a calcium level above 10.5 mEq/L; treatment includes limiting vitamin D and administering calcitonin.</p> Signup and view all the answers

    Name three types of IV fluids.

    <p>All of the above</p> Signup and view all the answers

    What is in a LR IV fluid?

    <p>Normal Saline plus electrolytes.</p> Signup and view all the answers

    When should you use NS IV fluids?

    <p>Use NS when trying to replace volume (plasma).</p> Signup and view all the answers

    What are the five stages of grief?

    <p>Denial, anger, bargaining, depression, and acceptance.</p> Signup and view all the answers

    What should you remember when someone is dealing with death and grief?

    <p>Encourage expression of anger and understand cultural customs surrounding death.</p> Signup and view all the answers

    What are nosocomial infections?

    <p>Infections acquired as a result of exposure to microorganisms in the hospital setting.</p> Signup and view all the answers

    What routes of transmission are related to HIV exposure?

    <p>Unprotected sexual contact, exposure to blood, and perinatal transmission.</p> Signup and view all the answers

    What is included in nursing assessment related to HIV?

    <p>Positive enzyme-linked immunosorbent assay (ELISA) confirmed with Western Blot Test.</p> Signup and view all the answers

    What should you know about HIV symptoms?

    <p>Flu-like symptoms may appear 1-3 weeks after exposure; can advance to severe weight loss and neurological disease.</p> Signup and view all the answers

    What does nursing and collaborative management for HIV include?

    <p>Monitoring disease progression, initiating ART, and managing symptoms.</p> Signup and view all the answers

    What are the goals of HIV drug therapy?

    <p>Reduce viral load, maintain CD4+ T cell counts, and delay development of HIV-related symptoms.</p> Signup and view all the answers

    What are some HIV medications?

    <p>All of the above</p> Signup and view all the answers

    What is the antidote for heparin toxicity?

    <p>Protamine sulfate.</p> Signup and view all the answers

    What is the antidote for coumadin toxicity?

    <p>Vitamin K.</p> Signup and view all the answers

    What is the antidote for too much ammonia?

    <p>Lactulose.</p> Signup and view all the answers

    What is the antidote for digoxin?

    <p>Digibind.</p> Signup and view all the answers

    What is the drug of choice for alcohol withdrawal?

    <p>Librium.</p> Signup and view all the answers

    What is the drug of choice to treat pain in patients who are narcotic addicts?

    <p>Methadone.</p> Signup and view all the answers

    Why should we be concerned about the patient receiving potassium and digoxin?

    <p>Potassium potentiates digoxin toxicity.</p> Signup and view all the answers

    What does heparin prevent?

    <p>Platelet aggregation.</p> Signup and view all the answers

    What is the medication of choice for V tach?

    <p>Lidocaine.</p> Signup and view all the answers

    What is the medication of choice for SVT?

    <p>Adenosine.</p> Signup and view all the answers

    What is the medication of choice for asystole?

    <p>Atropine.</p> Signup and view all the answers

    How often is nitroglycerin administered and when should you not give it?

    <p>Up to 3 times every 5 minutes; do not give when BP is less than 90/60.</p> Signup and view all the answers

    What does preload affect?

    <p>The amount of blood that goes to the right ventricle.</p> Signup and view all the answers

    What should you remember when selecting an NCLEX answer or determining the order of priority?

    <p>Use the ABC rule: Airway, Breathing, and Circulation. The exception is C-A-B for CPR.</p> Signup and view all the answers

    How should you address questions related to Maslow's Hierarchy of Needs?

    <p>Address physiological needs first, then safety, love and belonging, self-esteem, and self-actualization.</p> Signup and view all the answers

    What are the steps in the nursing process?

    <p>Assessment, Analysis, Planning, Implementation, and Evaluation.</p> Signup and view all the answers

    What are the normal ranges for Hemoglobin?

    <p>Male: 14-18, Female: 12-16, Newborn: 14-24.</p> Signup and view all the answers

    What are the normal ranges for WBC?

    <p>Both genders: 5000-10000, Newborn: 9000-30000.</p> Signup and view all the answers

    What are the normal ranges for RBC?

    <p>Male: 4.7-6.1 million, Female: 4.2-5.4 million.</p> Signup and view all the answers

    What are the normal ranges for Platelets?

    <p>150000-400000.</p> Signup and view all the answers

    What is the normal range for Potassium (K+)?

    <p>3.5-5.</p> Signup and view all the answers

    What is the normal range for Sodium (Na+)?

    <p>136-145.</p> Signup and view all the answers

    What is the normal range for Calcium (Ca+)?

    <p>9-10.5 for adults.</p> Signup and view all the answers

    What are the normal ranges for Magnesium (Mg+)?

    <p>1.7-2.2.</p> Signup and view all the answers

    What is the normal range for Chloride (Cl-)?

    <p>98-106.</p> Signup and view all the answers

    What is the normal range for Alkaline Phosphatase (ALP)?

    <p>30-120.</p> Signup and view all the answers

    What are the normal ranges for Blood Urea Nitrogen (BUN)?

    <p>10-20.</p> Signup and view all the answers

    What are the normal ranges for Creatinine?

    <p>Male: 0.6-1.2, Female: 0.5-1.1.</p> Signup and view all the answers

    What is the relationship between Calcium and Phosphorus (PO4)?

    <p>They have an inverse relationship.</p> Signup and view all the answers

    What are the normal ranges for Arterial Blood Gases (ABGs)?

    <p>pH: 7.35-7.45, pCO2: 35-45, HCO3: 22-26.</p> Signup and view all the answers

    What are the normal ranges for Prothrombin Time (PT)?

    <p>11-12.5.</p> Signup and view all the answers

    What are the normal ranges for International Normalized Ratio (INR)?

    <p>0.8-1.1.</p> Signup and view all the answers

    What are the normal ranges for Partial Thromboplastin Time (PTT) and Activated PTT (aPTT)?

    <p>PTT: 60-70, aPTT: 30-40.</p> Signup and view all the answers

    What are the 7 Rights of medication administration?

    <p>Right drug, right dose, right route, right time, right patient, right documentation, right to refuse.</p> Signup and view all the answers

    When should you draw a peak level?

    <p>30-60 minutes after medication administration.</p> Signup and view all the answers

    When should you draw a trough level?

    <p>30-60 minutes before medication administration.</p> Signup and view all the answers

    What should you teach new parents about introducing foods to infants?

    <p>Introduce one food at a time to help identify allergies.</p> Signup and view all the answers

    What is civil law concerned with?

    <p>Protection of the patient's private rights.</p> Signup and view all the answers

    What does criminal law deal with?

    <p>Rights of individuals and society as defined by legislative laws.</p> Signup and view all the answers

    What is nursing negligence?

    <p>Failure to exercise the proper degree of care required by circumstances.</p> Signup and view all the answers

    What is nursing malpractice?

    <p>Failure to use the degree of care that a reasonable nurse would use.</p> Signup and view all the answers

    Where do Standards of Care originate?

    <p>From Nurse Practice Acts, laws, accreditation recommendations, professional guidelines.</p> Signup and view all the answers

    What are nurses responsible for related to the standards of care?

    <p>Performing procedures correctly and exercising professional judgment.</p> Signup and view all the answers

    When can a nurse NOT follow the healthcare provider's prescription?

    <p>When the nurse believes it is in error, violates policy, or is harmful.</p> Signup and view all the answers

    What should a nurse do related to advanced medical directives?

    <p>Assess the patient's knowledge and integrate directives into the care plan.</p> Signup and view all the answers

    What is documented in a living will?

    <p>Wishes regarding future care in the event of terminal illness.</p> Signup and view all the answers

    What is a durable power of attorney for healthcare?

    <p>A document appointing a representative to make healthcare decisions.</p> Signup and view all the answers

    When can restraints be used?

    <p>To ensure safety when less restrictive interventions fail.</p> Signup and view all the answers

    How long can an involuntary admission last?

    <p>72 hours.</p> Signup and view all the answers

    What is HIPAA and what does it require?

    <p>Health Insurance Portability and Accountability Act of 1996 establishing privacy standards.</p> Signup and view all the answers

    What is required for informed consent to be valid?

    <p>The patient must be competent, legal age, and provide voluntary consent.</p> Signup and view all the answers

    What type of communication is 'do it my way'?

    <p>Aggressive communication/authoritarian leader.</p> Signup and view all the answers

    What type of communication is 'Whatever...as long as you like me.'?

    <p>Passive communication/laissez-faire leader.</p> Signup and view all the answers

    What type of communication is 'Let's consider the options available.'?

    <p>Assertive communication/democratic leader.</p> Signup and view all the answers

    What are the five rights of delegation?

    <p>Right task, right circumstance, right person, right direction, right supervision.</p> Signup and view all the answers

    What skills are needed for supervision?

    <p>Giving direction, evaluating, and following up.</p> Signup and view all the answers

    What does the acronym S-BAR stand for?

    <p>Situation, Background, Assessment, Recommendation.</p> Signup and view all the answers

    What are the three categories of pain medications?

    <p>Non-opioids, Opioids, Co-analgesic or adjuvant drugs.</p> Signup and view all the answers

    Name 4 types of Nonopioid Analgesics.

    <p>Acetaminophen, Salicylates, NSAIDs, COX-2 inhibitors.</p> Signup and view all the answers

    What type of drug is Aspirin?

    <p>Non-opioid Analgesic, Salicylates.</p> Signup and view all the answers

    What type of drug is Acetaminophen (Tylenol)?

    <p>Non-opioid Analgesic. Max dose: 4000 mg.</p> Signup and view all the answers

    What have NSAIDs (except aspirin) been linked to?

    <p>Increased risk for cardiovascular events; should not be taken by cardiac patients.</p> Signup and view all the answers

    At what pain level should an Opioid Analgesic be considered?

    <p>Pain level of 6 or greater.</p> Signup and view all the answers

    What does DO NOT delegate 'EAT' stand for?

    <p>Evaluate, Assess, Teach.</p> Signup and view all the answers

    What are some examples of Non-opioid Analgesic pain medications?

    <p>Acetaminophen, Aspirin, NSAIDs, COX-2 inhibitors.</p> Signup and view all the answers

    What are some types of Analgesics used for moderate to severe pain?

    <p>Mu agonists, Mixed agonist-antagonists, Partial agonists, Adjuvant drugs.</p> Signup and view all the answers

    What is a Mu agonist?

    <p>Drugs that activate opioid receptors while blocking others.</p> Signup and view all the answers

    When an opioid is prescribed with a non-opioid analgesic, what should you monitor?

    <p>The daily dose.</p> Signup and view all the answers

    Name 5 non-invasive non-pharmacological pain relief techniques.

    <p>TENS, heat and cold application, massage therapy, relaxation techniques, guided imagery.</p> Signup and view all the answers

    Name 3 invasive non-pharmacological pain relief techniques.

    <p>Nerve blocks, interruption of neural pathways, acupuncture.</p> Signup and view all the answers

    What can cause fluid volume excess?

    <p>Answer not provided.</p> Signup and view all the answers

    Study Notes

    NCLEX-RN Exam Review Key Points

    • ABCs of Priority Care: Focus on Airway, Breathing, and Circulation first; use C-A-B during CPR.

    • Maslow's Hierarchy of Needs: Prioritize physiological needs, followed by safety, love/belonging, esteem, and self-actualization.

    • Nursing Process Steps:

      • Assessment: Gather and verify data.
      • Analysis: Interpret data and determine diagnoses.
      • Planning: Prioritize and modify outcomes.
      • Implementation: Manage care and assign tasks.
      • Evaluation: Compare actual vs. expected outcomes.

    • Normal Ranges for Hemoglobin & Hematocrit:

      • Hemoglobin: Male 14-18, Female 12-16; Newborn 14-24.
      • Hematocrit: Male 42-52, Female 37-47; Newborn 44-64.

    • White Blood Cell Count: Normal range for both genders is 5,000-10,000; can increase due to stress or decrease due to drug therapy.

    • Red Blood Cell Count:

      • Males: 4.7-6.1 million, Females: 4.2-5.4 million.
      • Exercise and high altitude can increase levels; pregnancy usually lowers them.

    • Platelet Counts: Normal is 150,000-400,000; may increase with exercise or OC usage but decrease from hemorrhage or certain drugs (e.g., aspirin).

    • Electrolyte Ranges:

      • Potassium (K+): 3.5-5, specimen care prevents false elevation.
      • Sodium (Na+): 136-145, avoid drawing from an infusing IV.
      • Calcium (Ca+): 9-10.5; Thiazide diuretics can increase levels; positive Chvostek and Trousseau signs indicate hypocalcemia.

    • Urine and Blood Tests:

      • BUN normal range is 10-20; indicates kidney function with a 20:1 ratio with creatinine.
      • Creatinine: Male 0.6-1.2 mg/dL, Female 0.5-1.1 mg/dL.

    • Blood Gas Analysis: AC pH: 7.35-7.45, AL pCO2: 35-45, HCO3: 22-26.

    • Prothrombin Time (PT) Ranges: Normal PT 11-12.5 seconds; therapeutic range for Coumadin is 1.5-2 times normal.

    • International Normalized Ratio (INR): Normal range 0.8-1.1; individual target ranges for conditions like Afib and mechanical heart valves.

    • Nursing Responsibilities: Adhere to Standards of Care from Nurse Practice Acts, laws, and agency procedures; nurses must follow or report errors in HCP prescriptions.

    • Advanced Medical Directives: Assess patient knowledge, integrate into care plans, and provide information on limitations for life-prolonging measures when recovery is not probable.

    • Restraint Usage: Must ensure patient safety, requires written order, and mandates monitoring and documentation of alternatives tried and follow-up assessments.

    • Fluid Volume Management:

      • Excess: Causes include CHF and renal failure; symptoms involve edema and elevated BP. Treat with diuretics and monitoring.
      • Deficit: Causes include inadequate intake and hemorrhage; symptoms include weight loss and oliguria. Treat with isotonic fluids and strict I&O.

    • Electrolyte Imbalances:

      • Potassium (K+): Critical for osmotic pressure; imbalance can be life-threatening.
      • Sodium (Na+): Maintains osmotic pressure; fluid shifts depend on concentration variations.

    • Hyponatremia: Defined as Na+ <135 mEq/L; symptoms include confusion and muscle cramps; manage according to underlying causes.

    • Pain Management Categories: Non-opioids for mild pain, opioids for moderate-severe pain, and co-analgesics/adjuvants for neuropathic pain.

    • Informed Consent: Essential for validity; must be competent, voluntary, and fully informed of the procedure and risks involved.

    • Communication Styles in Leadership:

      • Aggressive/Authoritarian: "Do it my way."
      • Passive/Laissez-Faire: "Whatever...as long as you like me."
      • Assertive/Democratic: "Let's consider the options available."

    • Five Rights of Delegation: Right task, circumstance, person, direction/communication, and supervision.

    • Non-Pharmacological Pain Relief Techniques: Preferred options include TENS, heat/cold therapy, massage, relaxation, and guided imagery.

    • Invasive Pain Relief Techniques: Options include nerve blocks and acupuncture for targeted pain management.### Hypernatremia

    • Sodium level above 145 mEq/L.

    • Symptoms: pulmonary edema, seizures, thirst, fever.

    • Treatment: restrict sodium intake, avoid IV fluids containing sodium, and weigh daily.

    Hypokalemia

    • Potassium level below 3.5 mEq/L.
    • Cardiac effects: rapid, thready pulse, flat T waves, fatigue, anorexia, muscle cramps.
    • Treatment: IV potassium supplements (max 20 mEq/hr) and encourage potassium-rich foods (e.g., bananas, spinach).

    Hyperkalemia

    • Potassium level greater than 5 mEq/L.
    • Symptoms: tall, tented T waves, bradycardia, muscle weakness.
    • Treatment options: IV glucose with insulin, Kayexalate, and possibly renal dialysis.

    Hypocalcemia

    • Calcium level below 8.5 mEq/L.
    • Symptoms: positive Trousseau's and Chvostek's signs, diarrhea, numbness, convulsions.
    • Treatment: calcium and vitamin D supplements; slow IV calcium administration; increase dietary calcium.

    Chvostek's Sign

    • Tested by tapping the face just below the zygomatic bone.
    • Positive response: twitching of ipsilateral facial muscles, indicating neuromuscular excitability from hypocalcemia.

    Trousseau's Sign

    • Tested by inflating a sphygmomanometer cuff above systolic blood pressure.
    • Positive response: muscular contraction with wrist flexion and finger hyperextension, indicating hypocalcemia.

    Hypercalcemia

    • Calcium level above 10.5 mEq/L.
    • Symptoms include muscle weakness, constipation, nausea/vomiting, dysrhythmias, and behavioral changes.
    • Treatment: limit vitamin D, increase fluid intake, avoid calcium-based antacids, administer calcitonin, and renal dialysis if necessary.

    IV Fluids Classification

    • Isotonic: 0.9% NS, LR, D5W.
    • Hypotonic: 0.5% NS, 0.45% NS.
    • Hypertonic: D5 0.45% NS, D5LR, D5NS.

    Lactated Ringer's (LR)

    • Contains normal saline with added electrolytes.

    Normal Saline (NS) Use

    • Utilized for volume replacement (plasma).

    Stages of Grief

    • Denial, anger, bargaining, depression, acceptance.

    Support for Grieving Individuals

    • Encourage expression of anger.
    • Respect cultural customs regarding death and dying.

    Nosocomial Infections

    • Infections acquired in healthcare settings due to microorganisms.

    HIV Transmission Routes

    • Unprotected sexual contact, blood exposure through drug equipment, perinatal transmission (during pregnancy, delivery, breastfeeding).

    Nursing Assessment for HIV

    • Confirm positive ELISA results with Western blot test.
    • Use PCR for neonates and OraQuick for preliminary home testing; requires confirmation by a healthcare professional.

    HIV Symptoms

    • Initial flu-like symptoms appear 1 to 3 weeks after exposure.
    • Progression to severe weight loss, secondary infections, cancers, and neurological diseases over 8-10 years.

    HIV Management

    • Monitor disease progression and immune function.
    • Initiate ART to decrease viral load and increase T cell counts.
    • Prevent/manage opportunistic diseases and complications.

    Goals of HIV Drug Therapy

    • Reduce viral load, maintain or raise CD4+ T cell counts, delay symptoms, and ensure compliance.

    HIV Medications

    • NRTIs: zidovudine, lamivudine, abacavir, emtricitabine.
    • NtRTI: Tenofovir DF.

    Antidotes

    • Heparin toxicity: protamine sulfate.
    • Coumadin toxicity: vitamin K.
    • Ammonia excess: lactulose.
    • Digoxin toxicity: digibind.

    Alcohol Withdrawal Medication

    • Librium as the drug of choice.

    Pain Management in Narcotic Addicts

    • Methadone is used for detoxification and pain treatment.

    Potassium and Digoxin Concern

    • Potassium can enhance the risk of digoxin toxicity.

    Heparin Function

    • Prevents platelet aggregation.

    Cardiac Medications

    • Medication of choice for V tach: lidocaine.
    • Medication of choice for SVT: adenosine.
    • Medication of choice for Asystole: atropine.

    Nitroglycerin Administration

    • Administer up to 3 doses (every 5 minutes); do not give if blood pressure is less than 90/60.

    Preload

    • Refers to the volume of blood returning to the right ventricle.

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    Description

    This quiz covers essential concepts for the NCLEX-RN exam, focusing on priority care, Maslow's hierarchy, and the nursing process. It includes key normal ranges for hemoglobin, hematocrit, and white blood cell counts that are critical for nursing assessments. Prepare effectively by reviewing these vital points.

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