NCLEX RN STUDY GUIDE
NCLEX RN STUDY GUIDE
DO NOT DELEGATE WHAT YOU CAN EAT!
Evaluate
Assess
Teach
Don’t delegate Unstable patients
Initial
... [Show More] Assessment, Teaching, IV drips, Evaluations only RN
AIRBORNE TRANSMISSION-BASED PRECAUTIONS: MTV
Measles
TB
Varicella-Chicken Pox/Herpes Zoster-Shingles
Private Room: Negative pressure with 6-12 air exchanges/hr
Mask: N95 for TB
DROPLET TRANSMISSION-BASED PRECAUTIONS: Think of SPIDERMAN!
Sepsis
Scarlet fever
Streptococcal Pharyngitis (Streptococcus group A/ Strep Throat): Can Lead to Glomerulonephritis & Rheumatic
Parvovirus B19 Fever.
Pneumonia
Pertussis
Influenza/ Haemophilus influenza type B
Diphtheria (Pharyngeal): Serious bacterial infection.
Epiglottitis: Medial Emergency! No Throat Inspection.
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NCLEX RN STUDY GUIDE
Rubella/ German measles
Mumps
Meningitis/ Neisseria Meningitidis
Mycoplasma/ Meningeal Pneumonia
An - Adenovirus
Private Room or Cohort Surgical mask PRN for Procedures
Mask 3ft Distance
CONTACT PRECAUTION TRANSMISSION-BASED PRECAUTIONS: MRS.WEE
Multidrug resistant organism/ MRSA/ VRE
Respiratory infection
Skin infections
Wound infection
Enteric infection - Clostridium Difficile
Eye infection – Conjunctivitis
*MRSA - Contact precaution ONLY. Use Chlorhexidine Wipe!
*VRSA - Contact & Airborne precaution (Private room, door closed, negative pressure)
*SARS (Severe Acute Resp Syndrome) Airborne & Contact (just like Varicella)
SKIN INFECTIONS- VCHIPS- CONTACT
Varicella Zoster
Cutaneous Diphtheria (Bacteria Infection in the Wound)
Herpes Simplex
Impetigo (Bacterial Skin Infection)
Pediculosis (Lice)
Scabies (Itchy Skin condition. Burrowing Trail of the Scabies Mite)
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NCLEX RN STUDY GUIDE
Middle East Respiratory Syndrome (MERS): Viral respiratory illness caused by Coronavirus (MERS-CoV).
S/S: Fever, Cough, SOB, and Death. The Incubation Period is 5-6 days but can range from 2-14 days.
CDC: Standard (Gloves), Contact (Gown), Eye Protection (Goggles), Airborne Precautions (N95)
Negative room: Negative disease (TB, Disseminated Herpes Zoster)
Positive room: Protect the Patient (HIV, Cancer)
Addison’s= hyponatremia, hypotension, decreased blood vol, hypoglycemia, hyperKalemia, HyperCalcemia.
Cushing’s= HyperNatremia, HyperTension, Incr. Blood Vol, HyperGlycemia, hypokalemia, hypocalcemia.
Managing Stress in a patient with Adrenal Insufficiency (Addison’s) is paramount, because if the Adrenal
glands are stressed further it could result in Addisonian Crisis.
Addison’s: Remember BP is the most Important assessment parameter, as it causes Severe Hypotension.
Addison’s: (need to "add" hormone): Hypoglycemia, Dark pigmentation, Decr. Resistance to Stress, fractures,
Alopecia, Weight Loss, GI distress. Vitiligo. Mood swings (Normal)
Need to Report S/S of Infection/ Fever (Addisonian Crisis)
Tx: Mineral Corticoids.
Addisonian Crisis: Hypoglycemia, Confusion, n/v, Abd Pain, Extreme Weakness, Dehydration, Decr. BP.
Cushings: (have extra "Cushion" of Hormones): Hyperglycemia, prone to Infection, Muscle Wasting,
Weakness, Edema, HTN, Hirsutism, Moonfaced/Buffalo Hump
Cause: Excessive production of Corticotropin (Hyperplasia of the Adrenal Cortex) & Cortisol-secreting
Adrenal Tumor.
Prednisone Toxicity: Cushing’s syndrome- Buffalo Hump, Moon face, Hyperglycemia, Hypertension.
Acetaminophen: 10-20. Max 4000mg per day.
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Acetaminophen Poisoning: Possible Liver Failure for about 4 days. Close observation required.
Tx: (Antidote) n-AcetylCysteine/Mucomyst
AcetylSalicyclic Acid (ASA): Metabolic Acidosis.
S/S: Tinnitus, Coffee Ground Emesis (Old Blood), Black tarry stools (Melena), Bruising, Tachycardia,
Hypotension, GI Ulcers.
Tx: Activated Charcoal, then IV Na+ Carbonate.
Acromegaly: Coarse Facial feature. Assess Cardiac Problems (eg. S3, S4).
Acute Respiratory Distress Syndrome (ARDS):
The 1st Sign is Incr. Respirations. Later comes Dyspnea, Retractions, Air Hunger, Cyanosis.
Cardinal sign is Hypoxemia (Low O2 level in tissues).
Refractory Hypoxemia is the hallmark of ARDS, a progressive form of acute respiratory failure that has a high
Mortality rate. It can develop following a Pulmonary Insult (eg, aspiration, pneumonia, toxic inhalation) or
nonpulmonary insult (eg, sepsis, multiple blood transfusions, trauma) to the Lung.
The Inability to improve Oxygenation With Incr. in O2 concentration.
The insult triggers a Massive Inflammatory response that causes the lung tissue to release inflammatory
mediators (leukotrienes, proteases) that cause damage to the alveolar-capillary (A-C) membrane. As a result of
the damage, the A-C membrane becomes more permeable, and intravascular fluid then leaks into the alveolar
space, resulting in a Noncardiogenic Pulmonary Edema.
The lungs become Stiff and Noncompliant, which makes Ventilation and Oxygenation less than optimal and
results in increased work of breathing, tachypnea and alkalosis, atelectasis, and refractory hypoxemia.
ARDS (fluids in alveoli), DIC (Disseminated Intravascular Coagulation) are always Secondary to something
else (another disease process). – Impaired Gas Exchange.
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NCLEX RN STUDY GUIDE
PreOxygenated with 100% O2, and Suction should be applied for no more than 10 seconds to prevent
hypoxia. The nurse must wait 1-2 minutes between passes to ventilate to prevent hypoxia.
Deep reBreathing should be encouraged.
The Suction catheter should be No more than half the width of the artificial airway and inserted without suction.
Don Sterile gloves if it is not have a closed suction system.
Suction should be set at Medium Pressure (100-120 mm Hg for adults, 50-75 mm Hg for children) as Excess
pressure will traumatize the mucosa and can cause hypoxia.
Clients usually Cough as the catheter enters the trachea, and this helps loosen secretions. The catheter should
be advanced until resistance is felt and then, to prevent mucosal damage, Retracted 1 cm before applying
suction.
You will ask every New Admission if he has an Advance Directive, and if not you will explain it, and he will
have the option to sign or not.
Alcohol: a Toxin that causes CNS Depression. Alcohol withdrawal generally starts within 8 hours after the last
drink and peaks at 24-72 hours.
Acute alcohol intoxication: Confusion, Coordination Impairment, Drowsiness, Slurred Speech, Mood Swings,
and Uninhibited actions. Hypoglycemia.
Chronic Alcohol Abuse/Alcoholism: Benzodiapepine (lorazepam, diazepam, chlordiazepoxide) – to Treat
Gross Tremors, Seizures, Delirium symptom.
Chlordiazepoxide: For Alcohol withdrawal. Don’t take with Alcohol (terrible N/V can occur)
Thiamine (B1): to treat Wernicke Encephalopathy, a Serious complication that manifests as altered mental
status, oculomotor dysfunction, and ataxia. Also can lead to death or neurologic morbidity (Korsakoff
Psychosis). Give before or with IV Glucose.
Alzheimer’s Disease: Chronic, progressive, degenerative cognitive disorder that accounts for more than 60% of
All Dementias.
Memantine: Cognition Enhancing medication. It can treat Dementia associated with Alzheimer's disease.
Improve symptoms cognition, Daily function, Behavioral problems.
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NCLEX RN STUDY GUIDE
Donepezil: Cognition Enhancing medication.
Amyotrophic Lateral Sclerosis (ALS): a condition in which there is a Progressive, Degeneration of Motor
Neurons in both the Upper & Lower Motor Neuron systems.
Upper Motor Neuron issue: Hyper Reflexes
Lower Motor Neuron issure: Absent Reflexes
S/S: Limb weakness, Dysarthria (difficulty speaking), and Dysphagia.
Iron:
IM: should be given Z-track so they don't leak into SQ tissues
IV: Iron Dextran (Imferon). Can cause hypersensitivity reaction (anaphylaxis), test dose needs to be given First.
PO: give with Vitamin C or on an Empty stomach or Btw Meals. Place it on the back of the Month (Stain teeth).
Expect Black/Green Tarry Stools.
Take iron elixir with juice or water.... Never with milk (Vit D).
Iron Poisoning: GI Bleed.
Antidote: Deferoxamine
Iron Deficiency Anemia: Microcytic anemia.
S/S: Fatigue, Pallor, Fissures at the corner of the mouth, Spooning of the fingernail, Reduced exercise tolerance
Thalassemia Major (Cooley’s Anemia): Microcytic anemia.
S/S: Maxillary Hyperplasia, Frontal Bossing.
Caused by: Defects in both Beta-chains of the Hgb molecule.
Pernicious Anemia: Macrocytic anemia, Lack of required Intrinsic factor (B12 Deficiency)
S/S: Pallor, Tachycardia, Sore Red Tongue (Beefy tongue), Enlarged Liver that can lead to R-sided HF.
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NCLEX RN STUDY GUIDE
Take Vit. B12 for life.
Shilling Test: Test for Pernicious Anemia. How well one absorbs Vit B12
Folate (Folic Acid) Deficiency: Macrocytic anemia.
Risk: Alcoholism or Diet Low in Vegetables.
S/S: Stomatitis, Ulcerations on the tongue. Dysphagia, Flatulence, watery Diarrhea
Aplastic Anemia: Normocytic Anemia. Decline in blood cell production r/t to Bone Marrow Depression.
Can cause an Extremely Low Hgb of 7 g/dL
Severe Anemia: (Female hgb 11.7 ~ 15.5) Tachycardia. SOB (Dyspnea). Pallor.
(Male hgb 13.2 ~ 17.3)
Anorexic: Absence of Menstruation leads to Osteoporosis.
Bulimia: Chipmunk Face.
Antibiotic:
Obtain Cultures before starting IV antibiotics.
IV push should go over at least 2 Minutes.
Always check for Allergies before Administering (especially PCN).
Make sure Culture & Sensitivity has been done before First dose.
Give Prophylactic Antibiotic therapy before any Invasive Procedure.
Aminoglycocide ( _Mycin e.g. Vancomycin; except Erythromycin): Cause Nephrotoxicity and Ototoxicity.
Adverse Effects are Bean Shaped - Nephrotoxic to Kidneys & Ototoxic to Ears
Macrolide (Azithromycin, Erythromycin, Clarithromycin): can cause Prolonged QT interval. My lead to
Torsade de Pointes (Life-threatening Arrhythmias).
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NCLEX RN STUDY GUIDE
Antacids will Limit the Absorption of the antibiotics.
Concurrent use of other prolong QT interval (Amiodarone, Sotalol, Haloperidol, Ziprasidone, Azole,
Antifungals) will Incr. the risk.
Risk of Hepatotoxicity: when taken in High doses. Report Elevated AST and ALT.
Sulfamethoxazole/Trimethoprim: (Tx for UTI, PJP). Don’t take if Allergic to Sulfa drugs.
Drink plenty of fluids.
S/S: Diarrhea
Penicillin Allergy: No Cephalexin, Cephalosporin.
Amphotericin B: (antifungal) causes Hypokalemia. Premeditate Before giving. Pts will most likely get a Fever.
Mebendazole: (antiparasite) Take it with High Fat diet (increases absorption).
Anticholinergic Effects: Assessment
Blocks the action of Acetylcholine (Neurotransmitter), blocks involuntary muscle movement.
Many antihistamine (diphenhydramine) have anticholinergic effect.
Dry mouth (Xerostomia)- can't spit
Urinary retention- can't pee
Constipated- can't poop
Blurred vision- can't see
Decreased Acetylcholine is related to Senile Dementia.
Glucagon increases the effects of Oral Anticoagulants (Rivaroxaban).
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NCLEX RN STUDY GUIDE
Appendicitis: Pain is in RL quadrant with Rebound Tenderness. Continuous. Guarding. Anorexia. N/V.
McBurney’s Point – pain in RLQ indicative of appendicitis.
Position on Right side with legs flexed After Appendectomy.
Risk for Peritonitis.
Peritonitis: Mucus in Ileal Conduit is expected.
Blumberg’s Sign: Presence of rebound tenderness in the abdomen.
Aortic Dissection: Risk Factor: HTN
S/S: (Ascending)- Chest Pain, Radiate to the Back
(Descending)- Abrupt in Onset, “Worst Ever” “Tearing”, Ripping Pain, Moving Back Pain, Epigastric Pain
Abdominal Aortic Aneurysm (AAA): Definitive Diagnosis- CT scan.
Hypoactive BS for few days after the Surgery.
Computed Tomography (CT) Scan: Assess Allergies
Osteoarthritis: a Degenerative Disease, causing pain With Activity.
Inflammation occurs, but the joint does Not usually become swollen or red.
It commonly affects the Larger, weight-bearing joints and affects both genders equally.
Rheumatoid Arthritis: causes Pain and Inflammation After periods of rest.
It affects the Small joints (like fingers) and is more common in women.
Pain is usually the Highest Priority.
Heat for Chronic (Rheumatoid Arthritis): Warm Shower/Bath in the Morning.
Swimming is the Best.
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Order of Assessment: Inspection, Palpation, Percussion and Auscultation. Except…
Abdomen Assessment: Inspect, Auscultate, Percuss then Palpate (Last, bc it may induce pain)
Assessment with Kids: Least invasive to Most invasive.
An example of when you would Implement Before going through a bunch of Assessments is when someone is
experiencing Anaphylaxis. Get the Ordered Epinephrine in them STAT, especially if they clearly States the S/S
(Difficulty Breathing, Increasing Anxiety, etc.)
Anaphylaxis is a Medical Emergency.
Epinephrine Injection is the Only option for treating anaphylaxis.
Asthma:
Wheezing on Expiration.
Coughing Without other s/s is suggestive of asthma. If they stop Wheezing; it could mean it is Worsening.
Hyperrsonance: Percussed over Hyperinflated (air) Lung (Asthma, Emphysema).
Asthma and Arthritis: Swimming Best
Avoid ASA, NSAID (ibuprofen), and Beta Blockers.
Asthma has Intercostal Retractions (be Concerned)
Exacerbation: Acute, Distress. Wheezing, Dyspnea, Sternal Retraction, Anxiety.
Status Asthmaticus: Acute, Prolonged, and Severe Asthmatic Attack that is unresponsive to usual treatment.
Hospitalization is usually required.
When using a Bronchodilator inhaler in conjunction with a Glucocorticoid inhaler, administer the
Bronchodilator First.
Theophylline (Bronchodilator): Therapeutic Drug level: 10-20
Tx: of Asthma or COPD
Increases the Risk of Digoxin Toxicity, Decreases the effects of Lithium and Phenytoin.
Causes GI upset, give with food. [Show Less]