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NCLEX TIPS!...

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Nothing is impossible- the word itself says “I’m Possible” NCLEX TIPS 1) Do not read into the question- never assume anything that has not been specifically mentioned (in the question) and do not add extra meaning or history to the question—do not make up a story to validate choosing an answer 2) NCLEX land is set at Utopia  General Hospital- you have all the time, all the resources, and all the staff you need! 3) Least invasive to most invasive – least restrictive to most restrictive (restraints are rarely a good choice) 4) Avoid using absolutes- always, never, must, etc. 5) Assess the client first before implementing a treatment or action—if there’s a choice that pertains to assessment of the patient—it is usually the answer – assess unless in distress 6) Priority goes to assessments and answers that deal with the patient (patient-focused) directly and not with machines/monitors/equipment (unless the question is specifically asking about them) a. Ex: Auscultate fetal heart rate before checking the monitor 7) If it is the FIRST time doing something for or with the patient (such as vital signs upon admission to the floor/unit, or when a transfer is involved), the NURSE must complete the assessment- including vital signs 8) If patient is an adult, answers with family options can be ruled out (unless patient is not competent to make own decisions) 9) In emergency situations (mass casualty), patients with greater chance to live are treated first 10) If you are asked about the FIRST action you would take in a prioritization/discrimination question think: “If I can only do one action, and then I must go home, what will the outcome be?” 11) Therapeutic communication- reflect feelings and provide correct information 12) Do not ask “why” questions (or yes/no) and do not say “I understand” 13) An answer that delays care or treatment is usually wrong (Ex: reassess in 15 minutes, monitor the patient for a continuation of symptoms) 14) When determining interventions to enhance a client’s wellness, consider options that promote healthy nutrition, regular exercise, proper weight maintenance, proper rest, and avoidance of harmful chemicals (nicotine) and risk-taking behaviors (not wearing a seat belt) 15) If two of the answer choices are the exact opposite, one is probably the answer (ie. bradycardia, tachycardia)

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If two or three answers are similar, none are correct (*be careful—sometimes answers may seem similar but in fact are saying something different) Always look for the UMBRELLA option—one that is a broad universal statement and usually contains the concepts of the other options with it—often the correct answer If you have never heard of an answer—do not eliminate it—work around it…if you can safely eliminate all other answers, that is your answer—if you are down to two answers and you know one answer is right, go with what you know Prioritize actual problems over potential problems DO NOT leave the patient – think safety DO NOT “do nothing”- you always have to do something If the question is about endorsement—always report anything new or different to the next shift Only select “document” if the assessment is normal Put patients with the same or similar diagnoses in the same room-clean vs. dirty patients Never increase a patient’s fluids to “catch up” Answer SATA questions as true or false for each answer option Rephrase the question in your own words—this ensures you understand what the question is asking—if you cannot rephrase the question, you do not know what the topic is If you cannot determine the topic of the question, read all answer choices to help you understand the problem (look for patterns) Try not to determine the answer before reading the answer choices—NCLEX uses traps and answers that scream “pick me” but are wrong More often than not, pain will not be your answer -- pain is considered psychosocial—exception to this rule are signs and symptoms of compartment syndrome Try to focus on the here and now as much as possible With positioning questions- you are trying to prevent or promote something—evaluate the outcome of each option When the question asks what is ESSENTIAL—think SAFETY If you do not know what a word means, try to break it down using medical terminology a. Ex: Rhabdomyosarcoma – muscle (myo), tumor (sarcoma) → tumor of the muscle tissue b. Same idea applies to medications- use suffixes and prefixes to recognize classifications Make an educated guess—if you can’t make the best answer for a question after carefully reading it, choose the answer with the most information When in doubt, SAFETY 2

“Keep them breathing, keep them safe”

Prioritization Techniques ● Prioritize systemic vs. local (life before limb) ● Prioritize acute before chronic  ● Prioritize actual before potential future problems ● Prioritize according to Maslow’s- physiological needs before psychosocial  (acute safety can take priority- ATI) ● Recognize and respond to trends vs. transient findings (recognizing a gradual deterioration) ● Recognize signs of emergencies and complications vs. “expected client findings” ● Apply clinical knowledge to procedural standards to determine the priority action- recognizing that the timing of administration of antidiabetic and antimicrobial medications is more important than administration of some other medications How to tackle- WHO DO YOU SEE FIRST- questions: ● Who is your most stable patient? ELIMINATE ANSWER ● Who is your most stable patient (of the 3 remaining)? ELIMINATE ANSWER ● Who is your most unstable patient (of the 2 remaining)? Airway? Breathing? Circulation? SELECT ANSWER Transmission-Based Precautions AIRBORNE MTV M- measles T- TB V- Varicella (chicken pox), varicella zoster (disseminated shingles) *Private room- negative pressure with 6-12 air exchanges/hr, mask, N95 Chicken pox can be rapidly transmitted to other clients—should be isolated quickly and placed in negative pressure room

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CONTACT MRS. WEE M- multidrug resistant organism (MRSA) R- respiratory infection S- skin infections (localized herpes zoster) W- wound infections E- enteric infection →   clostridium difficile E- eye infection →   conjunctivitis (Also, Hep A) *A nurse with localized herpes zoster CAN care for patients as long as the patients are NOT immunocompromised and the lesions are covered!

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DROPLET SPIDERMAN S- sepsis S- scarlet fever S- streptococcal pharyngitis P- parvovirus B19 P- pneumonia (pneumonic plague) P- pertussis I- influenza D- diphtheria (pharyngeal) E- epiglottitis R- rubella R- respiratory syncytial virus (RSV) M- mumps M- meningococcal (infectious meningitis) M- mycoplasma or meningeal pneumonia An- adenovirus *Private room or cohort, mask (door open, 3ft distance) Current CDC evidence-based guidelines indicate that droplet precautions for clients with meningococcal meningitis can be discontinued when the client has received antibiotic therapy for 24 hours!

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Current CDC guidelines indicate that rapid implementation of standard, contact, and airborne precautions are needed for any client suspected of having SARS—in order to protect other clients and healthcare workers Skin Infections VCHIPS V- varicella zoster C- cutaneous diphtheria H- herpes simplex I- impetigo P- pediculosis S- scabies Impetigo- caused by Staph and Strep, untreated can cause acute glomerulonephritis (periorbital edema—indicates poststreptococcal glomerulonephritis)

Order of PPE Application ● Gown ● Mask ● Goggles/face shield ● Gloves Order of PPE Removal ● Gloves ● Goggles/face shield ● Gown ● Mask Because the hands of health care workers are the most common means of transmission of infection from one client to another, the most effective method of preventing the spread of infection is to make supplies for hand hygiene readily available for staff to use. Because the respiratory manifestations associated with the avian influenza are potentially life threatening, the nurse’s initial action should be to start oxygen therapy! ● S/S: SOB, diarrhea, abdominal pain, epistaxis ● Institute airborne and contact precautions According to the CDC, catheter associated UTIs are the most common health care-acquired infection in the US—primary CDC recommendations include avoiding the use of indwelling catheters and the removal of catheters as soon as possible! 6

Individuals who have contact with infants should be immunized against pertussis in order to avoid infection and to prevent transmission to the infant! The ventilator bundle developed by the Institute for Healthcare Improvement includes recommendations for continuous elevation of the head of the bed (30 to 45 degrees), daily assessment  for extubation readiness, and daily oral care with chlorhexidine solution. Chlorhexidine is more effective than the other options at reducing the risk for central-line associated bloodstream infections (CLABSIs) No pee, no K (do not give potassium without adequate urine output) ElVate Veins, dAngle Arteries for better perfusion *IV push should be given over 2 minutes* CONVERSIONS 1 oz 30 mL 1 cup 8 oz 1 kg 2.2 lbs 1 lb 16 oz 1 gr (grain) 60 mg *Convert C to F: C + 40 multiply by 9/5 and subtract 40 *Convert F to C: F + 40 multiply by 5/9 and subtract 40 Positioning _ Asthma ● Orthopneic position where patient is sitting up and bent forward with arms support on a table or chair arms Air Embolism- (S/S: chest pain, difficulty breathing, tachycardia, pale/cyanotic, sense of impending doom) ● Turn patient to LEFT side and LOWER  head of bed Pulmonary Embolism- (S/S: chest pain, difficulty breathing, tachycardia, pale/cyanotic, sense of impending doom) ● Elevate HOB Women in Labor with non-reassuring FHR- (S/S: late decels, decreased variability, fetal bradycardia, etc.) ● Turn mother on LEFT side (and give O2, stop Pitocin, increase IV fluids)

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Tube Feeding w/ Decreased LOC ● Head of bead ELEVATED (to prevent aspiration) and position patient on RIGHT side (promotes gastric emptying)

Postural Drainage ● Lung segment to be drained should be in the uppermost position to allow gravity to work During Epidural/Lumbar Puncture ● Side-lying (“C” curved spine)- lateral recumbent/fetal position Post Lumbar Puncture (LP) – (and also oil-based myelogram) ● Patient lies in flat supine (to prevent CSF leak and headache) for 2-3 hours ● Sterile dressing applied ● Frequent neuro checks Thoracentesis ● Position patient with arms on pillow over bed table or lying on side ● NO MORE THAN 1000cc at one time ● Post- check blood pressure, auscultate bilateral breath sounds, check for leakage, sterile dressing Patient with Heat Stroke ● Lie flat with legs elevated Hemorrhagic Stroke ● HOB elevated 30 degrees to reduce ICP and facilitate venous drainage Ischemic Stroke ● HOB flat (supine) During Continuous Bladder Irrigation (CBI)- catheter is taped to thigh ● Leg should remain straight to prevent pulling on catheter Post Myringotomy- surgical incision in eardrum to relieve pressure and drain fluid (tubes) ● Position on side of affected ear after surgery (allows drainage of secretions) Post Cataract Surgery ● Patient will sleep on unaffected side with night shield for 1-4 weeks (adequate vision may not return for 24 hours) 8

● Pain that is not relieved by prescription pain medication may signal hemorrhage, infection or increased ocular pressure Infant with Spina Bifida ● Position prone (on abdomen) to prevent sac from rupturing Buck’s Traction (skin traction) ● Elevate foot of bed for counter-traction Post Total Hip Replacement ● DON’T sleep on affected/operative  side ● DON’T flex hip more than 45-60  degrees ● DON’T elevate HOB more than 45 degrees ● Maintain hip abduction  by separating thighs with a pillow ● NO adduction or internal rotation Prolapsed Cord ● Knee-chest or Trendelenburg (goal is to prevent pressure on cord)

Vena Cava Syndrome (pregnant women) ● Position woman on her left side (relieves pressure off vena cava from fetus)—knees flexed (blood return) o Mother may present with hypotension Infant with Cleft Lip ● Position on back or in an infant  seat to prevent trauma to suture line ● While feeding, hold in upright position Infant with Cleft Palate ● Prone 9

Pancreatitis ● Patients should lie in fetal position ● Maintain NPO status (to rest the gut)—patient may also have PICC line inserted for TPN/lipids To Prevent Dumping Syndrome ● Eat in reclining position ● Lie down after meals for 20-30min ● Restrict fluids during meals, low carbohydrate, low fiber, high fat and protein ● *GOAL: decrease gastric motility Enema Administration ● Position patient in left-side lying (Sim’s position) with knees flexed Above Knee Amputation ● Elevate for first 24 hours on pillow ● Position prone daily to provide for hip extension ● Do not keep leg elevated beyond 24 hours—causes hip flexion which can lead to contractures ● Rewrap 3x day (elastic bandages) Below Knee Amputation ● Foot of bed elevated for first 24 hours ● Position prone daily to provide for hip extension ● Do not keep leg elevated beyond 24 hours—causes hip flexion which can lead to contractures *Activity helps reduce the frequency and degree of phantom pain Detached Retina ● Area of detachment should be in the dependent position (head in downward direction, lying on unaffected side) After Supratentorial Surgery (suture behind hairline) ● Elevate HOB 30-45 degrees After Intratentorial Surgery (incision at nape of neck) ● Position patient flat and lateral on either side During Internal Radiation 10

● On bed rest while implant is in place

*(Common NCLEX TOPIC) Autonomic Dysreflexia/Hyperreflexia (S/S: pounding H/A, profuse sweating, nasal congestion, goose flesh, bradycardia, HTN) ● Place patient in sitting position- HIGH FOWLER’S (elevate HOBFIRST ACTION)—decreases venous return ● Check for kinks in foley catheter tubing Spinal Cord Injury ● Immobilize on spine board ● Head in neutral position ● Immobilize with padded C-collar ● Maintain traction and alignment of head manually ● Log roll client and do not allow to twist or bend Shock ● Bed rest with extremities elevated 20 degrees, knees straight, head slightly elevated (modified Trendelenburg) Head Injury ● Elevate HOB 30 degrees to decrease ICP Peritoneal Dialysis when Outflow is Inadequate ● Turn patient from side to side BEFORE checking for kinks in tubing (according to Kaplan) Nasogastric Tube ● Elevate HOB 30 degrees to prevent aspiration ● Maintain elevation for continuous feeding or 1 hour after intermittent feedings Cardiac Catheterization ● Keep site extended (usually involves femoral artery) Post-thyroidectomy ● Semi-Fowler’s position, prevent neck flexion/hyperextension (support head, neck and shoulders) ● Trach at bedside ● Monitor respiratory status every hour Post-Bronchoscopy 11

● Semi Fowler’s ● Check V/S q15 min until stable ● Assess for respiratory difficulty (stridor, dyspnea resulting from laryngeal edema or laryngospasm)

Epistaxis ● Upright and lean forward (prevent blood from entering the stomach and to avoid aspiration) Pelvic Exam ● Lithotomy position Rectal Exam ● Knee-chest position, Sim’s, or dorsal recumbent Post-Liver Biopsy ● Place patient on right side over a pillow to prevent bleeding (liver is very vascular) ● No heavy lifting for 1 week’ Paracentesis ● Semi-Fowler’s or upright on edge of bed ● Void prior- prevent puncture of bladder ● Post- V/S (BP), report elevated temp, observe for signs of hypovolemia Pneumonia ● Lay on affected side to splint and reduce pain ● Trying to reduce congestion: the sick lung goes up Post-Appendectomy ● Position on right side with legs flexed GERD ● Lay on left side with HOB elevated 30 degrees (increases sphincter pressure) Postural Drainage ● Head in dependent position

Post-Radical Mastectomy ● Position in Semi-Fowler’s with arm (affected side) elevated – if left mastectomy, elevate left arm, if right mastectomy, elevate right arm! 12

o This facilitates removal of fluid through gravity and enhances circulation

Think positively and you can achieve great things! Prior to liver biopsy it is important to check lab results for PT time (vascular organ) Liver biopsy- (prior) administer Vitamin K, NPO at midnight, teach patient that he will be asked to hold breath for 5-10 sec, supine position with upper arms elevated Morphine is contraindicated   in pancreatitis—  it causes spasm of the Sphincter of Oddi—Demerol is the pain medication of choice! *After pain relief, it is important to cough and deep breathe in pancreatitis—because fluid is pushing up in the diaphragm *With chronic pancreatitis, pancreatic enzymes are given with meals

Diabetes Mellitus- pancreatic disorder resulting in insufficient or lack of insulin production leading to elevated blood sugar ● Type I (insulin dependent)- immune disorder, body attacks insulin producing beta cells with resulting Ketosis (result of ketones in blood due to gluconeogenesis from fat) o Excessive thirst and weight loss are characteristic of T1DM ● Type II (insulin  resistant)- beta cells do not produce enough insulin or body becomes resistant ● NCLEX Points o Assessment ▪ 3 P’s ● Polyuria (excessive urination), polydipsia (extreme thirst), polyphagia (excessive hunger) ▪ Elevated blood sugar ▪ Blurred vision ▪ Elevated HbA1C ▪ Poor wound healing ▪ Neuropathy ▪ Inadequate circulation ▪ End organ damage is a major concern due to damage to vessels ● Coronary artery disease o HTN, cerebrovascular disease 13

● Retinopathy o Therapeutic Management ▪ Insulin ● Required for Type I and for Type II when diet and exercise do not control blood sugar ● Assess for and teach the patient regarding peak action time for various insulins o Only administer short acting insulins IV ● Do not use vial that appears cloudy (NPH is the exception) ▪ Patient should monitor blood sugar before, during, and after exercise ▪ Patient should use protective footwear to prevent injury ▪ Infections and wounds should receive meticulous care ▪ Foot Care (inspect daily) ● Feet should be kept dry ● Footwear should always be worn (cotton socks are recommended as well as properly fitted shoes) ● Should not wear tight fitting socks ▪ Sick Day – when patients with DM become ill, glucose levels become elevated ● Continue to check blood sugars and do not withhold insulin ● Monitor for ketones in urine ▪ 15 Rule ● If blood sugar is low, administer 15g carbohydrates (5 lifesavers, 6 oz juice)- recheck in 15 minutes ▪ Complications ● Lipoatrophy o Loss of subq fat at injection site (alternate injection sites) ● Lipohypertrophy o Fatty mass at injection site ● Dawn phenomenon o Reduced insulin sensitivity between 5-8AM o Evening administration may help o Adjust evening diet, bedtime snack, insulin dose, and exercise to prevent early morning hyperglycemia – adjust do not eliminate (usually intermediate acting insulin is used) ● Somogyi phenomenon o Night time hypoglycemia results in rebound hyperglycemia in the morning hours

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Rapid-acting insulin should only be given if food is available and patient is ready to eat Repaglinide is a meglitinide analog drug—short-acting agents used to prevent postmeal blood glucose elevation—should be given within 1 to 30 minutes before meals and cause hypoglycemia shortly after dosing when a meal is denied or omitted

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Drawing up regular insulin and NPH together Cloudy (air into NPH) Clear (air into regular) Clear (draw up regular) Cloudy (draw up NPH) Or RN- regular before NPH Hypoglycemia requires urgent treatment ● Signs and Symptoms o Hunger o Irritability o Weakness o Headache o BG < 60 ● Consume 10 to 15g of carbohydrate (15-Rule) ● Glucose should be retested in 15 min ● Patient should eat a small snack of carbohydrate and protein if the next meal is more than an hour away ● Repeat carbohydrate treatment if symptoms do not resolve Al...