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FUNDAMENTALS: NCLEX

ABCS
Better than 1,2,3ABCs are always the first priority.

AIRWAY

Is it clear? If it isnt, well never get to the next letter:

BREATHING

If this isnt possible oxygen wont reach the lungs and be transported around the body

in the blood, know as:

CIRCULATION

Without which hypoxia and cardiac arrest will ensue.

These are the basic lifesaving principals and they combine with that only slightly lesser
known phrase, look, listen, and feel. Look in the mouth to make sure airway is clear, listen
for breath, and feel for pulse. Whether
in the ER, the OR, or on the floors this
is nursing 101.

MASLOWS HIERARCHY OF
NEEDS
Human needs are ranked on an
ascending scale according to how
essential those needs are for survival.
Abraham Maslow ranked human needs
on five levels.
1.

PHYSIOLOGIC NEEDS

Needs such as air, food, water,


shelter, rest, sleep activity, and
temperature maintenance, are
crucial for survival.
2.

SAFETY AND SECURITY


NEEDS The need for safety has both physical and psychological aspects. The person needs to feel
safe, both in the physical environment and in relationships.

3.

LOVE AND BELONGING NEEDS

The third level of needs includes giving and receiving

affection, attaining a place in a group, and maintaining the feeling of belonging.


4.

SELF-ESTEEM NEEDS

The individual needs both self-esteem (i.e., feelings of independence,

competence, and self-respect) and esteem from others (i.e., recognition, respect, and appreciation).
5.

SELF-ACTUALIZATION

When the need for self-esteem is satisfied, the individual strives for

self-actualization, the innate need to develop ones maximum potential and realize ones abilities and
qualities.

Human needs serve as a framework for assessing behaviors, assigning priorities to outcome
criteria, and planning nursing interventions.

THE NURSING PROCESS


The nursing process is a systematic, rational method of planning and providing
individualized nursing care. In the simplest terms the nursing process is:
1.

ASSESSING

2.

DIAGNOSING

3.

OUTCOME/PLANNING

4.

IMPLEMENTING

5.

EVALUATING

Collecting data.
Figuring out what is the problem.
How to best manage the problem.

Putting the plan into action.

Did the plan work?

The five phases of the nursing processes are not singular entities. They often overlap, for
example, assessment is often carried out while implementing and evaluating. The nursing
process allows for RNs to use time and resources more efficiently, to both their own and
their clients benefit.

THE SIX RIGHTS


They are called the rights of medication administration. All medication errors can be
linked, in some way, to an inconsistency in adhering to these rights when giving meds to
patients.
1.

RIGHT CLIENT

To identify a client correctly, the nurse must check the medication administration

form against the clients identification bracelet and ask the client to state his or her name to ensure the
ID band is correct.
2.

RIGHT MEDICATION

This is a multi-step process. The medication should be check against the

medication order and the medication label. Nurses should only administer medications they prepare and
verify. If an error occurs, the nurse who give the medication is the one responsible for the error.
If a client questions the medication a nurse is about to give it is important not to administer it until it
can be rechecked against the prescribers order. An alert client will know if a medication is different from
those received before.
3.

RIGHT DOSE

The unit dose system is designed to minimize errors. If a medication must be

prepared from a larger volume or strength than needed or when the prescriber orders an amount
different than what the pharmacy supplies, the chance for a mistake multiplies. When performing
medication calculations or conversions, have a colleague, another qualified RN check the calculated
dose.
4.

RIGHT TIME

The nurse must understand why a medication is ordered for certain times of day and

whether that time schedule can be altered.


5.

RIGHT ROUTE

If a prescribers order does not designate a route of administration such as orally

or by injection or IV (intravenously) the nurse must consult the prescriber. If the prescribed route is not
the recommended route the nurse should double check with the prescriber.

6.

RIGHT DOCUMENTATION

This is a fairly new addition to the traditional Five Rights but

has been widely adopted by facilities and caregivers. Many medication errors result from inaccurate
documentation. The documentation should clearly reflect the patients name, the name of the ordered
medication, the time the drug was given and the medications dosage, route and frequency. After giving
the medication the MAR must be completed per facility policy.

HEART

BASICS
PULMONARY CIRCULATION: Unoxygenated- R side of heart
Unoxygenated blood flows from inferior and superior vena cava

Right Atrium

Tricuspid Valve

Right Ventricle

Pulmonic Valve

Lungs

Through Pulmonary System

SYSTEMIC CIRCULATION: Oxygenated-L side of heart


Oxygenated blood flows from pulmonary veins

Left Atrium
Mitral Valve
Left Ventricle
Aortic Valve
Systemic Circulation

CARDIAC CYCLE: The actual time sequence between ventricular contraction and ventricular
relaxation
SYSTOLE: Simultaneous contraction of the ventricles
DIASTOLE: Synonymous with ventricular relaxation; when ventricles fill passively from the
atria to 70% of blood capacity

SOUNDS
S1 Tricuspid & Mitral Valve Closes
S2 Pulmonary & Aortic Valve Closes
S3 Ventricular Filling Complete
S4 Elevated Arterial Pressure (Atrial Kick)

WAVE REVIEW

P Wave : Atrial
depolarization

PR Segment : AV
node conduction

QRS Complex :
Ventricular
Depolarization

U Wave : Hypokalemia
creates U-wave
INDEPTH

ST Segment :
Ventricles depolarized

T Wave: Ventricular

P WAVE: Small upward wave indicating atrial depolarization


repolarization
QRS COMPLEX: initial downward deflection followed by large
upright wave, followed by small downward wave; represents
ventricular depolarization; masks arterial repolarization;
enlarged R portion- enlarged ventricles; enlarged Q portion
may indicate probable heart attack
T WAVE: Dome shaped wave; Indicates ventricular repolarization; flat when insufficient O2;
elevated when K levels
P-R INTERVAL: Interval from beginning of P wave to R wave; represents conduction time from
initial excitation to initial ventricular excitation; Good diagnostic tool; usually normal <0.25

S-T SEGMENT: Time from the end of S to beginning of T wave; represents time between end of
spreading impulse through ventricles and ventricular repolarization; in heart attack; with
insufficient oxygen
Q-T INTERVAL: Time for singular depolarization and repolarization of the ventricles. Conduction
probs, myocardial damage, or congenital heart defects can prolong this.

ECG CHANGES WITH MI


T wave inversion
ST segment elevation
Abnormal Q waves

ECG CHANGES WITH DIGITALIS

Inverts T wave

QT segment shorter

Decreases ST segment

ECG CHANGES WITH QUINIDINE

Inverts T wave

Q segment longer

QRS segment longer

ECG CHANGES WITH K+


Hyperkalemia: Lowers P Wave; width of QRS
Hypokalemia: Lowers T wave; causes U

ECG CHANGES WITH CA

Hypercalcemia: makes a longer QRS segment


Hypocalcemia: increases time of QT interval

BRAIN

PERSONAL PROTECTIVE EQUIPMENT (PPE)


Unless otherwise specified, assume that PPE includes: Gowns, Goggles, Mask, Gloves
The proper place for donning (putting on) PPE is outside of the room
The proper order for donning PPE is:
1. Put on gown
2. Put on mask
3. Put on goggles
4. Put on gloves
The proper place for removing (doffing) PPE is inside room
The proper order for removing PPE is:
1. Gloves
2. Goggles
3. Gown
4. Mask need to take mask off outside so you dont breathe in contaminated air
In airborne precautions ONLY, the mask is removed outside of the room

PSYCHIATRIC NURSE TEST-TAKING


PRINCIPLES
Phase Specificity
The best psych answers are those answers that are most appropriate to the phase of the nurse-patient therapeutic relationship
that you are in
If the question tells you the phase of the relationship, the phase will be the determinant of which answer is correct
The phases of the nurse-patient relationship:
The Pre-Interaction Phase
Purpose: For the nurse to explore his/her own feelings. To prevent judgmental, intolerant reactions.
Length: Begins when you learn you are going to be caring for someone and ends when you meet them.
Correct Answer(s): The nurse will explore her/his own feelings about
The Introductory Phase
Purpose: To establish trust and explore/assess
Length: Begins when you first meet the patient and ends when a mutually agreed-upon care plan is in place
Key Words:
These phrases are designed to hint to you that you are in the introductory phase:
o 1. During the initial interview
o 2. Upon admitting the patient..
o 3. On admission
o 4. At your first few meeting with..
o 5. While assessing
o 6. On the day of admission
o 7. While formulating nursing diagnoses
Correct answers: Should be very tolerant, accepting, explorative, probing, nosy. Be warm and fuzzy
The Working Phase (Therapeutic Phase)
Purpose: To implement the plan of care
Length: From the finished care plan until discharge
Key Words:

1. During the therapeutic interview


2. While implementing the care plan..
3. While working on the care plan goals
4. During treatment sessions..
5. During therapy..
6. In your weekly session..
7. Three days after admission
8. After improving..
Correct Answers:
Should be very focused, directive, tough. In some ways these answers will seem stern and slightly unfriendly. Set limits.
Enforce proper communication.
The Termination Phase
The only question asked here has been, When does the termination phase begin?
The answer On admission
GIFT GIVING
In psych, do not give something of value to the patient. Conversely, do not accept something of value from the patient
A gift is something of tangible or intangible value given from one person to another.
Gifts include: hugs, kisses, compliments, opinions, holding hands, placing an arm around, etc
DO NOT do these behaviors in psych. (May be appropriate in med-surg)
Difference between complimenting and observing progress
ADVICE-GIVING
DO NOT GIVE ADVICE. Let the patient formulate own solutions and alternatives.
Remember, giving advice and setting limits are not the same. The former is bad, the latter is good.
KEY WORDS TO AVOID:
1. Suggest that..
2.Advise the patient to..
3. Tell the patient to..
4. If I were you, I would
5. You should do..
6. You ought to..
7. You should NOT do..
8. Dont do
9. Recommend that
Any words with these phrases violate this principle and are WRONG. RULE THEM OUT!
Always say, And what do you think you should do, Mr. Smith?
GUARANTEE GIVING
DO NOT GIVE GUARANTEES IN PSYCH. You cannot predict the human mind of know anothers experience
Giving guarantees is okay in Med/Surgif true
KEY WORDS:
1. If youthen
2. You will improve if you..
3. We can

A guarantee violates trust when the promised results do not appear


Only things can guarantee: 1) meds will work 2) you are safe
IMMEDIACY
The best psych answers communicate to the patient that the nurse is willing to deal with the patients problem right then and right
there
Key Phrases:
AVOID answers like these
1. Refer patient to
2. Have you spoken to yourabout this?
3. Why dont you talk to yourabout this?
Avoid changing the subjectunless you are refocusing a patient who is avoiding the subject of therapeutic session
CONCRETENESS
The best psych answers are those answers that say exactly what they mean in a literal senseword for word
KEY PHRASES: Avoid slang, figurative speech, sayings, proverbs, verses, poetry, stories, parables, allegories, neologisms.

Tie-Breakers
1.
2.
3.
4.
5.

Why questions are not as good


Reflection is good.
Open-ended is better than closed-ended.
Answers with I, me, we, us in the subject are not good.
Shortest answers are the best

HANDWASHING AND GLOVING


Handwashing
Handwashing versus Scrubbing
Handwashing
Hands below elbows

Scrubbing
Elbows below hands

Length
Handles
When

Seconds
Yes; sink with handles
Upon entry or leaving room before and
after gloving, when soil hands

Minutes
No sink with handles
When patient is immunosuppressed
for any reason

Use

Soap and water

Something with chloro in it

Position

Use an Alcohol-Based Solution


1. On entering or leaving a room
2. Before putting on gloves, after taking off gloves
3. Cannot after soil hands!!
What about after using the rest room? must use soap and water
Dry from cleanest (hand) to dirtiest (elbow)
Turn water off with new paper towel
Sterile Gloving
Glove dominant hand first.
Grasp outside of cuff.

Touch only the inside of glove surface.


Do not roll cuff.
Fingers inside of second glove cuff.
Keep thumb abducted back.
Only touch outside surface of glove
Skin touches inside of glove
Outside of glove only touches outside of glove
Remove glove to glove
Skin to skin

INTERDISCIPLINARY CARE
Identifying which patients need interdisciplinary caredifferent than prioritizing who would most benefit from a team
working together on their care
Patients who do not need interdisciplinary care: Patients who need or have multiple doctors
Patient who DO need interdisciplinary care:
1. Major Criteria
a. Patients with multi-dimensional needs
i. For example:
1. Physical
2. Psychological
3. Social
4. Spiritual
5. Intellectual needs
b. Patients who need rehabilitation
2. Minor Criteria [choosing between patients]
a. A patient whose current treatment is ineffective
b. A patient who is preparing for discharge
EMPATHY
The best psych answers are those answers that communicate to the patient that the nurse accepts that patients feelings as
being valid, real, and worthy of action.
Key Phrases: A low-empathy answer is always wrong
Avoid Saying:
1. Dont worry
2. Dont feel

3. You shouldnt feel


4. I would feel
5. Anybody would feel
6. Nobody would feel
7. Most people would feel
Four Steps to Answering Empathy Questions
1. Recognize that it is an empathy question
Empathy questions have a quote in the question, and each of the answers contains a quote.
2. Put yourself in the clients shoes. Say their words as if you really meant them.
3. Ask yourself, If I said those words and really meant them, how would I be feeling right now?
4. Choose the answer that reflects the feelings...not the answer that reflects their words.