front 1 Therapeutic Communication | back 1 1. Respond with feeling tone 2. Provide information 3. Do not ask "why" 4. No yes/no questions 5. Do not focus on the nurse 6. Do not explore 7. Never say "dont worry" |
front 2 Therapeutic Communication | back 2 We communicate therapeutically with everyone in NCLEX land-> think "listen, reflect, provide info or ask open ended questions" listen to your client=what is the topic? (what do they want to talk about) and reflect on that topic |
front 3 Who do you see FIRST | back 3 -The most unstable (Who is going to die first) -Compare each patient to the next; eliminate the more stable of the patients -Consider: ABC Acute vs Chronic Expected vs Unexpected Actual vs Potential -Eliminate each stable patient until you have most unstable |
front 4 Assignment Strategy | back 4 RN: assessment, teaching, evalution i.e. admit, discharge, change in condition, etc LPN: stable patients with predictable outcomes i.e. gather data, recognize norms, know sterile procedures NAP: standard unchanging procedures i.e VS, o2 sats, ADLs, blood glucose, etc (remember, if you would allow the patient to do it at home safety, most likely it would be safe for the NAP to do) Think: it is a risk for aspiration? is it safe? |
front 5 Decision Tree | back 5 Step 1: Topic Step 2: Gathering Data vs Implementation Step 3: Physical vs Psychosocial Step 4: ABCs Step 5: Outcome -All outcomes must be safe and effective |
front 6 ABC | back 6 Airway Breathing Circulation |
front 7 Triage | back 7 Actual vs Potential Acute vs Chronic Expected vs Unexpected ABCs |
front 8 Decide if a question is... | back 8 Priority or Evaluation |
front 9 Priority Questions | back 9 BEST, MOST, FIRST -Use all 5 steps of the tree -If it is a statement, even if is has priority words in it, it could still be an evaluation, but if it is an action, it is a priority |
front 10 When gathering data | back 10 Decide if it is NEED to know or GOOD to know |
front 11 If unsure if it is a priority or evaluation question... | back 11 Just go down the decision tree anyway |
front 12 When a patient is using crutches.. | back 12 they should come to about 1-2 in below axillary |
front 13 5 Ps | back 13 Perastesia (no feeling) Pulselessness (no pulse) Pallor (pale) Paralysis (cant move) -Added by kaplan instructor Poikilothermia (feels cool to touch) |
front 14 Mantoux test | back 14 TB skin test |
front 15 People before.. | back 15 Paperwork |
front 16 Dialysis | back 16 Feel the thrill |
front 17 Hypercalcemia | back 17 Can damage CNS (8.5-10.5) |
front 18 Contraindications for birth control | back 18 Circulatory issues |
front 19 Pay attention to extreme words | back 19 ALL, NEVER, ALWAYS, INSISTS, IMMEDIATELY, SUDDEN, REQUIRED, NONE, MOST, ONLY, etc |
front 20 Mongolian spots | back 20 Bluish-black pigmented skin on an african american infant |
front 21 Always chart... | back 21 detailed observations (paint the oncoming nurse a vivid picture) |
front 22 What happens when a pregnant female lays on her back? | back 22 It compresses the vena cava flat and can cause her to faint (feel dizzy and nauseous at first) |
front 23 Should a pregnant women receive live virus injections? | back 23 No, it should be done after baby is born and the women should not get pregnant for atleast 4 weeks after |
front 24 Elderly+Antibiotics+Foul smelling stools=? | back 24 C. Diff= highly contagious Gi infection. Elderly clients are at a greater risk for C. Diff related to atrophy (shrinks) of thier GI cells. Antibiotics destroy normal flora = C. Diff has a party and grows in the elderly population |
front 25 Fires | back 25 RACE: Rescue, Alarm, Contain, Extinguish |
front 26 Environmental temp.. | back 26 can change skin color |
front 27 When using crutches | back 27 Think up with the bad and down with the good When going up the stairs, advance the good leg first. When going down the stairs, advance the bad leg first |
front 28 Conpartment Syndrome | back 28 Think 5 Ps |
front 29 When in doubt, ask yourself... | back 29 Is this the safest option |
front 30 When Studying Pharmocology | back 30 Study the classifications of meds (Antihypertensives) and each family in that classification (ACE inhibitors/Beta blockers/Calcium Channel blockers/Diurectics). The classification tells you what the meds action is (antihypertensives- decrease BP). The family generally will all act the same, have similar side effects, nursing considerations (ACE inhibitors – dry cough is an adverse reaction). Understand the action and effects on the body. Pay attention to nursing consideration. |
front 31 Strategy for answering questions | back 31 If your topic includes something you "suspect" is happening -> a data answer that "validates/confirms" (gives you concrete evidence of what you thought was happening) = an appropriate priority answer option. You want to confirm what you suspect before you implement thus that data answer helps you help the client/situation. |
front 32 Decision Tree To help you remember, and so you can take with you during your NCLEX
exam - | back 32 -First finger - index finger = Step 1 Identify your topic *points you
in the right direction. -2nd Finger - Middle finger = Step 2 Data vs
Implementation **Validation = "confirms" what you were thinking. An example is you have a client that is diabetic and jittery -- you think (“suspect”) possible "hypoglycemia". A data answer that "validates" what you were thinking would be "getting the blood sugar". The blood sugar gives you concrete evidence -**validation** of what you thought was going on. A data answer that “validates” is an appropriate priority answer option. -3rd Finger -Ring Finger = Step 3 Maslow - Physical vs Psychosocial
4th Finger -pinky-Step 4 ABC's 5th Thumb = Step 5 Evaluation ***Now, you can't raise that hand unless you have your
arm--**remember your arm is your content review You CAN do it –the Decision Tree will help you think better and get you were you need to be. Stay in control of every question and be confident with the strategies you have learned and practiced. Remember –as long as you are getting question = you are still in the game –don’t give up. |
front 33 Think before you answer... | back 33 Is your topic a physical or psychosocial topic? your answer should match i.e You want to know if your client is in pain.. Topic: pain (psychosocial) Answer: Ask you client to rate the pain (psychosocial) A wrong answer would be.. Observe your clients urinary cath.. It didnt say your client was unconscious so you would ask first. |
front 34 RICE | back 34 Rest Ice Compression Elevation (moderate ankle sprain) |
front 35 Balanced suspension traction | back 35 Weights should be hanging freely |
front 36 DASH Diet | back 36 Dietary Approaches to Stop Hypertension -fruits, veggies, potassium, decreased salt, etc |
front 37 PEG Tube | back 37 Percutaneous Gastrostomy Tube -sewn in -you want to compare tube length to the measurement recorded after insertion to verify placement -want in high fowlers -warm feeding to room temp |
front 38 Tubes | back 38 Remember, tubes are just an extension of your patient, observe before reporting, unless life threatening ie Patient with a urinary cath complains of having the need to urinate... You will want to observe for kinks, etc *Never secure tubing to bed linens or rail but upper abdomen is okay |
front 39 Isometric | back 39 Same length -So if your patient was preforming isometric exercises you would want the muscle to stay the same length, no stretching, so i.e placing the foot on the ground and pushing down, it is cramping the calf muscle but it is not stretching it |
front 40 COAL | back 40 Cane Opposite Affected Leg -Remember up with good, down with bad -Cane should be at the level of the greater trochanter |
front 41 If a patient has had a long leg fracture... | back 41 Shortness of breath is indicator of fat embolism -24-72 hours post fracture is highest risk If high respiratory rate with some apnea is a answer, it is not right. Even though apnea may be more severe than shortness of breath, you have to read the whole answer. The high respiratory rate is compensating for the apnea. So, in this case, shortness of breath is more extreme |
front 42 "Do not explore" Therapeutic Communication. What does it mean? | back 42 It mean exploring the patients delusions or hallucinations |
front 43 Depression-- aceSS | back 43 Lower case-- decreased -appetite -concentration -energy Upper Case-- Increased -Social Isolation -Sleep |
front 44 Withdrawal Tip | back 44 No matter the substance, withdrawal is the opposite of the effect of the substance i.e Alcohol is a depressant, so therefor, the withdrawal effects will be stimulation.. cant sleep, diarrhea, shaky hands, tremors, etc |
front 45 Alcohol Withdrawal | back 45 CNS stimulation-- excitability-- mild symptoms occur 6-12 hours after last drink |
front 46 Tip on Cocaine | back 46 Stimulant will effect the heart-- tachycardia |
front 47 Stages of Grief-- SAR | back 47 Shock and disbelief Awareness of the pain (loved one was experiencing) Restitution/Resolutions |
front 48 TIP | back 48 If the face is red, raise the bed If the face is pale, raise the tail (trouble breathing--face will be read-- raise the HOB) (If in shock--face is pale--trendelenburg--feet up head down) |
front 49 When positioning.. think.. | back 49 What are you trying to prevent? What are you trying to promote? |
front 50 Urine specific gravity | back 50 1.002 and 1.030 The higher the # the less fluid--dehydration-- urine is more concentrated therefor weights more The lower the # the more fluid--more diluted--fluid overload--weights less |
front 51 Urine output | back 51 Minimum- 30ml/hr (not normal but stable) Normal: 1500mL/day (about 62.5ml/hr) |
front 52 Heart Failure | back 52 Left--Lungs Right--Rest of body |
front 53 Erbs Point | back 53 Left sternal border, 3rd intercostal space --Think.. E backwards is 3 (and it rhymes)= 3rd intercostal space |
front 54 Valve sounds | back 54 All People Eat Taco Meat Aortic Pulmonic Erbs point Tricuspid Mitral (bicuspid or apical) |
front 55 Homonymous Hemianopsia | back 55 Can happen with a stroke -Loss of half of the vision in both eyes and is common with Unilateral Neglect -patient may turn head side to side when eating |
front 56 Herbals | back 56 If its got a G it'll make 'em bleed -Ginko, Garlic, Ginseng, etc |
front 57 St johns wart | back 57 Contraindication for blood thinners because it can act like vit K |
front 58 MRI concerns | back 58 Metal in the body (M&Ms) (MRI & Metal) -Pearcings, Intra-uterine implant, pacemaker, etc |
front 59 For a Fem-pop bypass.. | back 59 You never want to remove the dressing just reinforce (you cant see insertion site) -If you believe the patient may be bleeding internally, check BP |
front 60 Side Effects vs Adverse Effects | back 60 SE- more common, less severe AE- more intense, more life-threatening |
front 61 Cephalosporins and Penicillin | back 61 Are cousins, share some of the same reaction Patient that is allergic to one may be allergic to the other |
front 62 What lab to look at with Warfarin? | back 62 INR |
front 63 What lab to look at with Heprin? | back 63 PTT Think--Ptt--squish the 2 Ts together (tt) and you have an H (heprin) |
front 64 Ace Inhibitors | back 64 Give them Ace they will cough in you face -Common adverse reaction is dry cough |
front 65 Stupor | back 65 Not responsive |
front 66 Albuterol | back 66 Stimulates lungs--stimulates side effects--tachycardia Think--did we stimulate TOO MUCH? Is patient stable? |
front 67 Nitropatch | back 67 Should be removed at night to reduce the chance of tolerance build up |
front 68 NCLEX land | back 68 Is a perfect world, you have everything you would ever need -keep personal experience out! -You only have 1 patient unless otherwise stated |
front 69 When answering | back 69 Eliminate wrong answer first -Answer must relate to topic -If one part of the answer is wrong, The WHOLE thing is wrong -Is this the safest answer? -no "What-ifs" -If question says left or right side, take your hand and place it on that side so that you dont forget |
front 70 Vertical Chain of command | back 70 When supervisor is notified |
front 71 Strategy for answering Risk factor questions Who is at high risk? | back 71 Go through each answer and make a tally for each risk in that answer and at the end put the number of tallys in order and boom you have your answer |
front 72 Peripheral vs Central Cyanosis | back 72 Understand that "core measure" (inside the body) gives us the best info on client status. Environmental temp can change skin color. note the pattern--ear, hands, and lips are on the periphery/Conjuctivae is encased in the body (core) |