ATI NCLEX Tips

Name: ATI NCLEX Tips
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Author: Alice Edwards

Quick Med-Surg & Lab Reference Guide: Includes normal lab values, isolation precautions, assessment order, mobility aids use, delegation rules, and key mnemonics for cardiac, infection control, and emergency care. Great for nursing reviews!

Alice Edwards

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Laboratory Values:
Sodium 136-145 mEq/L
Potassium 3.5-5.0 mEq/L
Total Calcium 9.0-10.5 mg/dL
Magnesium 1.3-2.1 mg/dL
Phosphorus 3.0 -4.5 mg/dL
BUN 10-20 mg/dL
Creatinine 0.6 - 1.2mg/dL males, 0.5 - 1.1 mg/dL females
Glucose 70-105 mg/dL
HgbAlc <6.5%
WBC 5,000-10,000/mm--
RBC Men 4.7-6.1 million/mm-: Women 4.2-5.4 million/mm 2
Hemoglobin Men 14-18g/100 mL, Women 12-16 g/100 mL
Hematocrit Men 42-52%,Women 37-47%
Platelet 150,000-40 0,00 0/mnrP
pH 7.35-7.45
pC02 35 to45 mm Hg
p02 80-100 mmHg
HCO3 21-26mmol/L
Normal PT = 11-12.5 sec, Normal INR = 0.7-1.d (Therapeutic INR 2-3)
Normal PTT = 30-40 sec (Therapeutic PTT 1.5- 2 x normal or control values)
Digoxin 0.5 to 2.0ng/mL
Lithium 0.8 to 1.4 mEq/L
Dilantin 10-20 mcg/mL
Theophylline 10 to 20mcg/mL
1

Latex Allergies:
Note that clients allergic to bananas, apricots, cherries, grapes, kiwis, passion fruit,
avocados, chestnuts, tomatoes, and/or peaches may experience latex allergies as well.
Orde of assessment:
l-inspection
P-paIpation
P-percussion
A-auscultation
Except with abdomen it is lAPP-inspect, auscultate, percuss and palpate.
Cane walking:
C-cane
O-opposite
A-affected
L-leg
Crutch walking:
Remember the phase "step up" when picturing a person going up stairs with crutches.
The good leg goes up first followed by the crutches and the bad leg. The opposite
happens going down the stairs....OR "up to heaven...down to hell
Delegation:
RNs DO NOT delegate what they can EAT - evaluate, assess, teach
Helpful tool to remember Isolation Precautions:
AIRBORNE: "My Chicken Hez TB"
-Measles
-Chicken pox
-Herpes zoster
-TB
Management: neg. pressure room, private room, mask, n-95forTB

DROPLET: ”SPIDE RMAn”
-Sepsis
-Scarlet Fever
-Strep
-Pertussis
-Pneumonia
-Parvovirus
-Influenza
-Diphtheria
-Epiglottitis
-Rubella
-Mumps
-Adenovirus
Management: Private room /mask
CONTACT: "MRS WEE”
-MRSA
-VRSA
-RSV
-Skin infections (herpes zoster, cutaneous diphtheria, impetigo, pediculosis, scabies,
and staphylococcus)
-Wound infections
-Enteric infections (Clostridium difficile)
-Eye infections (conjunctivitis)
Management: gown, gloves, goggles, private room

Med-Surg Tips:
Angina Precipitating Factors: 4 E's
Exertion: physical activity and exercise
Eating
Emotional distress
Extreme temperatures: hot or cold weather
Arterial Occlusion: 4 P's
Pain
Pulselessness or absent pulse
Pallor
Paresthesia
Congestive Heart Failure Treatment: MADD DOG
Morphine
Aminophylline
Digoxin
Dopamine
Diuretics
Oxygen
Gasses: Monitor arterial blood gasses
Heart Murmur Causes: SPASM
Stenosis of a valve
Partial obstruction
Aneurysms
Septa] defect
Mitral regurgitation
Heart Sounds: All People Enjoy the Movies
Aortic: 2nd right intercostal space
Pulmonic: 2nd left intercostal space
Erb's Point 3rd left intercostal space
Tricuspid: 4th left intercostal space
Mitral or Apex: 5th left intercostal space

Hypertension Care: DIURETIC
Daily weight
Intake and Output
Urine output
Response of blood pressure
Electrolytes
Take pulse
Ischemic episodes orTIAs
Complications: CVA, CAD. CHF. CRF
Shortness of Breath (SOB) Causes: 4As+4Ps
Airway obstruction
Angina
Anxiety
Asthma
Pneumonia
Pneumothorax
Pulmonary Edema
Pulmonary Embolus
Stroke Signs: FAST
Face
Anns
Speech
Time
Compartment Syndrome Signs and Symptoms: 5 P's
Pain
Pallor
Pulse declined or absent
Pressure increased
Paresthesia
Shock Signs and Symptoms: CHORD ITEM
Cold, clammy skin
Hypotension
Oliguria
Rapid, shallow breathing
Drowsiness, confusion
Irritability
T achycardia
Elevated or reduced central venous pressure
Multi-organ damage

Hypoglycemia Signs: TIRED
Tachycardia
Irritability
Restlessness
Excessive hunger
Depression and diaphoresis
Hypocalcemia Signs and Symptoms: CATS
Convulsions
Arrhythmias.
Tetany
Stridor and spasms
Hypokalemia Signs and Symptoms: 6 L's
Lethargy
Leg cramps
Limp muscles
Low, shallow respirations
Lethal cardiac dysrhythmias
Lots of urine (polyuria)
Hypertension Complications: The 4 C's
Coronary artery disease (CAD)
Congestive heart failure (CHF)
Chronic renal failure (CRF)
Cardiovascular accident (CVA): Brain attack or stroke
Traction Patient Care: TRACTION
Temperature of extremity is assessed for signs of infection
Ropes hang freely
Alignment of both' and injured area
Circulation check (5 P's)
Type and location of fracture
Increase fluid intake
Overhead trapeze
No weights on bed or floor

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Cancer Early Warning Signs: CAUTION UP
Change in bowel or bladder
A lesion that does not heal
Unusual bleeding or discharge
Thickening or lump in breast or elsewhere
Indigestion or difficult}’ swallowing
Obvious changes in wart or mole
Nagging cough or persistent hoarseness
Unexplained weight loss
Pernicious Anemia
Leukemia Signs and Symptoms: ANT
Anemia and decreased hemoglobin
Neutropenia and increased risk of infection
Thrombocytopenia and increased risk of bleeding
Clients Who Require Dialysis: AEIOU (The Vowels)
Acid base imbalance
Electrolyte imbalances
Intoxication
Overload of fluids
Uremic symptoms
Asthma Management: ASTHMA
Adrenergics: Albuterol and other bronchodilators
Steroids
Theophylline
Hydration: intravenous fluids
Mask: oxygen therapy
Antibiotics (for associated respiratory infections)
Hypoxia: RAT (signs of early) BED (signs of late)
Restlessness
Anxiety
Tachycardia and tachypnea
Bradycardia
Extreme restlessness
Dyspnea

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Pneumothorax Signs: P-THORAX
Pleuritic pain
Tracheal deviation
Hyperresonance
Onset sudden
Reduced breath sounds (and dyspnea)
Absent fremitus
X-ray shows collapsed lung
Transient Incontinence Causes: DIAPERS
Delirium
Infection
Atrophic urethra
Pharmaceuticals and psychological
Excess urine output
Restricted mobility
Stool impaction
Dealing with Constipation:
Constipation is difficult or infrequent passage of stools, which may be hard and dry.
Causes include: irregular bowel habits. psychogenic factors, inactivity. chronic laxative use or
abuse, obstruction, medications, and inadequate consumption of fiber and fluid.
Encouraging exercise and a diet high in fiber and promoting adequate fluid intake may help
alleviate symptoms.
Dealing with Dysphagia:
Dysphagia is an alteration in the client's ability to swallow.
Causes include:
Obstruction
Inflammation
Edema
Certain neurological disorders
Modifying the texture of foods and the consistency of liquids may enable the client to achieve
proper nutrition.
Clients with dysphagia are at an increased risk of aspiration. Place the client in an upright or
high-Fowlef s position to facilitate swallowing.
Provide oral care prior to eating to enhance the client's sense of taste.
Allow adequate time for eating, utilize adaptive eating devices. and encourage small bites and
thorough chewing.
Avoid thin liquids and sticky foods.

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Dumping Syndrome:
Dumping Syndrome occurs as a complication of gastric surgeries that inhibit the ability of the
pyloric sphincter to control the movement of food into the small intestine.
This "dumping" results in nausea, distention, cramping pains, and diarrhea within 15 min after
eating.
Weakness, dizziness, a rapid heartbeat, and hypoglycemia may occur.
Small, frequent meals are indicated.
Consumption of protein and fat at each meal is indicated.
Avoid concentrated sugars.
Restrict lactose intake.
Consume liquids 1 hr before or after eating instead of with meals (a dry diet).
Gastroesophageal Reflux Disease (GERD):
GERD leads to indigestion and heartburn from the backflow of acidic gastric juices onto the
mucosa of the lower esophagus.
Encourage weight loss for overweight clients.
Avoid large meals and bedtime snacks.
Avoid trigger foods such as citrus fruits and juices, spicy foods, and carbonated beverages.
Avoid items that reduce low'er esophageal sphincter (LES) pressure, such as alcohol, caffeine,
chocolate, fatty foods, peppermint and spearmint flavors, and cigarette smoking.
Peptic Ulcer Disease (PUD):
PUD is characterized by an erosion of the mucosal layer of the stomach or duodenum.
This may be caused by a bacterial infection with Helicobacter pylori or the chrome use of
non-steroidal anti-inflammatory drugs (NSAIDs), such as aspirin and ibuprofen.
Avoid eating frequent meals and snacks, as the}' promote increased gastric acid secretion.
Avoid alcohol, cigarette smoking, aspirin and other NSAIDs, coffee, black pepper, spicy foods,
and caffeine
Lactose Intolerance:
Lactose intolerance results from an inadequate supply of lactase, the enzyme that digests
lactose.
Symptoms include distention, cramps, flatus, and diarrhea.
Clients should be encouraged to avoid or limit their intake of foods high in lactose such as: milk,
sour cream, cheese, cream soups, coffee creamer, chocolate, ice cream, and puddings.
Diverticulosis and Diverticulitis:
A high-fiber diet may prevent diverticulosis and diverticulitis by producing stools that are
easily passed and thus decreasing pressure within the colon.
During acute diverticulitis, a low’-fiber diet is prescribed in order to reduce bowel stimulation.
Avoid foods with seeds or husks.
Clients requue instruction regarding diet adjustment based on the need for an acute inten’ention
or preventive approach.

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Cholecystitis:
Cholecystitis is characterized by inflammation of the gallbladder. The gallbladder stores and
releases bile that aids in the digestion of fats.
Fat intake should be limited to reduce stimulation of the gallbladder.
Other foods that may cause problems include coffee, broccoli, cauliflower. Brussels sprouts,
cabbage, onions, legumes, and highly seasoned foods.
Otherwise, the 'diet is individualized to the client's needs and tolerance.
Nephrotic Syndrome:
Nephrotic syndrome results in serum proteins leaking into the urine.
The goals of nutritional therapy are to minimize edema, replace lost nutrients, and minimize
permanent renal damage.
Dietarc recommendations indicate sufficient protein and low-sodium intake.
Nephrolithiasis (Kidney Stones):
Increasing fluid consumption is the primary intemention for the treatment and prevention of the
formation of renal calculi Exc essive intake of protein, sodium, calcium, and oxalates (rhubarb,
spinach, beets) may increase the risk of stone formation.
Acute Renal Failure (ART):
ARE is an abrupt, rapid decline in renal function. It is usually caused by trauma, sepsis, poor
perfusion, or medications. ARE can cause hyponatremia, hyperkalemia, hypocalcemia, and
hyperphosphatemia. Diet therapy for ARE is dependent upon the phase of xARF and its
underlying cause.

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Pre-End Stage Renal Disease Ipre-ESRD):
Pre-ESRD, or diminished renal reserve renal insufficiency, is a predialysis condition characterized by an
increase in serum creatinine.
Gcals of nutritional therapy for pre-ESRD are to:
Help preserve remaining renal function by limiting the intake of protein and phosphorus.
Control blood glucose levels and hypertension. which are both risk factors.
Protein restriction is key for clients with pre-ESRD.
Slows the progression of renal disease.
Too little protein results in breakdown of body protein, so protein intake must be carefully determined .
Restricting phosphorus intake slows the progression of renal disease.
High levels of phosphorus contribute to calcium and phosphorus deposits in the kidneys.
Dietary recommendations for pre-ESRD:
Limit meat intake.
Limit dairy products to W cup per day.
Limit high-phosphorus foods (peanut butter, dried peas and beans, bran, cola, chocolate, beer, some whole
grains).
Restrict sodium intake to maintain blood pressure.
Caution clients to use vitamin and mineral supplements ONLY when recommended by tlreir provider.
End Stage Renal Disease (ESRD):
ESRD. or chronic renal failure, occurs when the glomerular filtration rate (GFR) is less than 25 mL min.
the serum creatinine level steadily rises, or dialysis or transplantation is required.
The goal of nutritional therapy is to maintain appropriate fluid status, blood pressure, and blood
chemistries.
A high-protein, low-phosphorus. low-pota&sium, low-sodium. fluid-restricted diet is recommended.
Calcium and vitamin D are nutrients of concern.
Protein needs increase once dialysis is begun because protein and amino acids are lost in the dialysate.
Fifty percent of protem intake should come from biologic sources (eggs, milk, meat, fish, poultry, soy).
Adequate calories (35 cal kg of body weight) should be consumed to maintain body protein stores.
Phosphorus must be restricted.
The high protein requirement leads to an increase in phosphorus intake.
Phosphate binders must be taken with all meals and snacks.
Vitamin D deficiency occurs because the kidneys are unable to convert it to its active form.
This alters the metabolism of calcium, phosphorus, and magnesium and leads to hyperphosphatemia,
hypocalcemia, and hypermagnesemia.
Calcium supplements will likely be required because foods high in phosphorus (which are restricted) are
also high in calcium.
Potassium intake is dependent upon the client's laboratory values, which should be closely monitored.
Sodium and fluid allowances are determined by blood pressure, weight, serum electrolyte levels, and
urine output.
Achieving a well-balanc ed diet based on the above guidelines is a difficult task. The National Renal Diet
provides clients with a list of appropriate food choices.

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Cleft lip: nursing care plan (postoperative) — "CLEFT LIP
Crying, minimize
Logan bow
Elbow restraints
Feed with Brecht feeder
Teach feeding techniques; two months of age (average age at repair)
Liquid (sterile water), rinse after feeding
Impaired feeding (no sucking)
Position—never on abdomen
Complication of severe preeclampsia — "HELLP"
syndrome
Hemolysis
Elevated Liver enzymes
Low Platelet count
Dystocia: general aspects (maternal)—'MP's"
Powers
Passageway
Passenger
Psych
Infections during pregnancy — "TORCH"
Toxoplasmosis
Other (hepatitis B, syphilis, group B beta strep)
Rubella
Cytomegalovirus
Herpes simplex virus
IUD: potential problems with use — "PAINS"
Period (menstrual: late, spotting, bleeding)
Abdominal pain, dyspareunia
Infection (abnormal vaginal discharge)
Not feeling well, fever or chills
String missing
Newborn assessment components — "APGAR"
Appearance
Pulse
Grimace
Activity
Respiratory effort

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Obstetric (maternity) history — "GTPAL"
Gravida
Term
Preterm
Abortions (SAB, TAB)
Living children
Oral contraceptives: Signs of potential problems —
"ACHES"
Abdominal pain (possible liver or gallbladder problem)
Chest pain or shortness of breath (possible pulmonary embolus)
Headache (possible hypertension, brain attack)
Eye problems (possible hypertension or vascular accident)
Severe leg pain (possible thromboembolic process)
Preterm infant: Anticipated problems — "TRIES"
Temperature regulation (poor)
Resistance to infections (poor)
Immature liver
Elimination problems (necrotizing enterocolitis [NEC])
Sensory-perceptual functions (retinopathy of prematurity [ROP])
VEAL CHOP-which relates to fetal heart rate.
Variable decels => Cord compression (usually a change in mothers position helps)
Early decels => Head compression (decels mirror the contractions; this is not a sign of
fetal problems)
Accelerations => O 2 (baby is well oxygena ted-this is good)
Late decels => Placental utero insufficiency (this is bad and means there is decreased
perfusion of blood/oxygen/nutrients to the baby).
Nine-point Postpartum Assessment...BUBBLEHER
B- Breasts
U- Uterus
B- Bladder
B- Bov el function
L- Lochia
E- Episiotomy
H- Hemorrhoids
E- Emotional Status
R- Respiratory System

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Considerations for the pregnant client
Admittance of a pregnant client to a medical-surgical unit:
You may have a pregnant client admitted with a diagnosis unrelated to her pregnancy
and, therefore, she may be admitted to a general medical-surgical floor. A mnemonic to
assist you in performing important assessment elements for these clients is FETUS.
* F: Document fetal heart tones every shift. To assess fetal heart tones, use a handheld
Doppler ultrasound and place it in an area corresponding to uterine height. For
example, for a client who’s less than 20 weeks pregnant, the most likely area to find
fetal heart tones is at the pubic hairline or the symphysis pubis. For a client whose
pregnancy is more advanced, such as at 24 weeks, the fetal heart rate can most
probably be heard midline between the symphysis pubis and the umbilicus. As the
pregnancy advances in weeks, fetal heart tones can be heard closer to and possibly
above the umbilicus.
* E Provide emotional support. Pregnant women who are experiencing unexpected
medical conditions are at a high level of anxiety related to how the current medical
problem may affect the fetus. You should take extra care to alleviate and reduce your
client's anxiety by explaining all medications and treatments. Additionally, be prepared
to listen for fetal heart tones anytime the client requests it to further reduce her worry of
the fetus' well-being.
* T: Measure maternal temperature. Because your client's core body temperature is
higher than you can detect through oral or tympanic thermometers, be alert to the
presence of a fever. A high maternal temperature can lead to fetal tachycardia and
distress. An order for antipyretics on admission to ensure their quick availability will be a
prudent request you should make to the admitting physician.
* U: Ask about uterine activity or contractions. Make it a normal part of your routine to
ask about any type of uterine pain, tightening, or discomfort throughout your shift. Be
aware that early contractions often present as lower back pain. Don't attribute
complaints of lower back pain to the hospital bed. If your client reports any unusual
activity, take care to softly palpate the lower abdomen for periods of greater than 2
minutes while conversing with her. Watch for subtle changes of facial expression while
simultaneously detecting a change in uterine tone. If contractions are suspected, your
client will need to be monitored with continuous fetal monitoring in the labor and delivery
unit.
* S: Assess for the presence of and changes in sensations of fetal movement. After 20
weeks gestation, all women should be able to report feeling the fetus move. This is an
important assessment to perform and document at least every shift, easily
accomplished by asking "How often are you feeling the baby move?" By asking this as
an open-ended question, you'll receive more information about the quantity of fetal
movement such as, "I haven't felt the baby move as much as usual today."

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Admittance of a postpartum client to a medical-surgical
unit
There are times when a woman may be hospitalized during the postpartum period for a
medical condition. When this occurs, she'll most likely be placed on a general
medical-surgical unit. Her admission will cause you to ask: "What's normal during the
weeks following the birth of a baby?"
* Breasts Within the first 24 hours postpartum, colostrum appears and is followed by
breast milk within the first 72 hours. Breast engorgement is most likely to occur around
day 4 postpartum. The engorged breast will appear full, taut and even shiny. Although
this is normal, it may be very uncomfortable for your client In contrast, a woman with
mastitis will usually run a fever higher than 100" F, report feeling "ill," and have one
breast that's affected (firm, inflamed, swollen, and exquisitely tender to touch). If your
client is breastfeeding her newborn, she'll require a breast pump. Depending on the
medications ordered, the milk may need to be disposed of and not used for the baby.
* Lochia. Sometimes women will experience lochia (vaginal discharge) until the time of
their 6-week postpartum visit. Immediately after delivery, the lochia is red and heavy
enough to require a pad change every 1 to 2 hours. By 7 days postpartum, the lochia
should be lighter in color (pink to red) and amount, requiring a pad change every 4
hours. Lochia that becomes heavier, has a foul odor, and is accompanied by pelvic pain
isn’t a normal finding and requires immediate intervention.
* Perinea/ care. For the first 2 weeks following delivery, clients will need to perform
perineal hygiene as taught during the immediate postpartum period. This may include
perineal water rinses following elimination using warm water or medicinal rinses, use of
sitz baths, and comfort medications to the perineal and anal area.
* Cesarean section. If your client delivered her baby via cesarean section, continued
assessment of the surgical incision is warranted for the first 2 to 3 weeks postpartum.
Redness and warmth around the incision, excessive bruising around the incision, or
incisional drainage requires immediate intervention. If the surgeon used staples to close
the incision, they're usually removed approximately 5 days post-delivery.
Remember, the hospitalized postpartum client is likely to be very emotional. Not only will
she be experiencing the normal hormonal fluctuations of the postpartum period, she
may also be distraught leaving her newborn at home and feeling that she's missing
bonding lime with her child. Visitation between the mother and her infant may be very
limited to minimize the infant's risk of infection, but visits should be arranged if at all
possible.

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ATI NCLEX Tips

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