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NCLEX-LABS > NCLEX LABS > Flashcards

NCLEX LABS Flashcards

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1
Q

INR

A

2-3

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2
Q

INR >4

A

C= Critical.

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3
Q

When INR is critical (Greater than 4)

A

Hold Coumadin
Assess For Bleeding
Prepare Vitamin K
Call Doctor

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4
Q

Creatinine? (Best Indicator
of Kidney Function)

A

0.6-1.2 (Same as Lithium)

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5
Q

Elevated Creatinine Greater than 1.2 =

A

A (Abnormal)
Do nothing.

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6
Q

Potassium

A

3.5-5.3

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7
Q

Low Potassium (Less than 3.5) = C (Critical)

A

C (Critical)

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8
Q

What should you do if your K is low?
(Less than 3.5)

A

Assess Heart
Prepare to Give K
Call Doctor

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9
Q

Elevated Potassium?
If it’s 5.4-5.9 =

A

Critical
High but Still in the 5’s

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10
Q

What to do if K is in Critical Range?
(5.4-5.9)

A

Hold K
Assess Heart
Prepare Kayexalate + D5W+Regular Insulin

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11
Q

Potassium Over 6?

A

D= DEADLY DANGEROUS. DO SOMETHING NOW.

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12
Q

When Potassium is over 6 you?

A

First get Vitals.
Then get help, Look for severe acidosis - that’s what this is and is the biggest priority.

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13
Q

BUN?

A

8-30

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14
Q

Elevated BUN? (Over 30)

A

B. Be concerned

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15
Q

What do you do if BUN is elevated?
(Over 30)

A

Check for Dehydration

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16
Q

Hemoglobin?12-18. Remember Teenage hemoglobin

A

12-18

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17
Q

If Hemoglobin is moderately low (8-11) B. (Be concerned). Check for Bleeding.

A

B. (Be concerned). Check for Bleeding.

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18
Q

What do you do if Hemoglobin is less
than 8?

A

C= Critical.
Assess for Bleeding
Prepare Blood Transfusion
Call Doctor

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19
Q

HCO3 (Bicarb)?

A

22-26 (Young Adult Age)

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20
Q

Normal Bicarb?

A

A= Abnormal. Not really concerned

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21
Q

CO2?

A

35-45

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22
Q

Beware, C02 Range doesn’t count in?

A

COPD Patients

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23
Q

If CO2 is in the 50s?

A

C= Critical

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24
Q

What should you do if C02 is in the 50s?

A

Assess Respiratory Status
Do Pursed Lip Breathing
Never Pick Give 02!!!

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25
Q

If the CO2 is the 60s?

A

D= Respiratory FAILURE

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26
Q

What should you do if CO2 is in the 60s?

A

Assess Respiratory Status
Do Pursed Lip Breathing
Prepare for Intubation
Call Respiratory
Call MD

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27
Q

Hematocrit (HCT)

A

36-54
Abnormal= B.

28
Q

What should you do if Hematocrit is Elevated?

A

Assess for Dehydration

29
Q

PO2
(This is Partial 02 in Arterial blood. From
ABG Only)

A

78-100

30
Q

Kind of Low P02 ? (70-77)

A

C= Critical

31
Q

What should you do if P02 is 70-77?

A

Assess Respiratory Status
Give 02

32
Q

P02 < 60

A

D= DEADLY DANGEROUS

33
Q

What should you do if P02 is really low?

A

Assess Respiratory Status
Give Respiratory Status
Prepare 02
Call Respiratory
Call Doctor

34
Q

02 Saturation

A

93-100 (Lower than 95 is bad for Peds
pts)

35
Q

Always ____ for 02 levels

A

Over React

36
Q

If 02 is less than 93
C= Critical.

A

Assess Respiratory
Give 02

37
Q

BNP Normal

A

< 100

38
Q

If BNP is Elevated

A

B. Be Concerned. Look for signs of CHF

39
Q

SODIUM (NA)

A

135-145
If NA is Abnormal It’s a B

40
Q

If SODIUM (NA) is Abnormal WITH A change in
LOC

A

C= Critical. Huge Safety Risk

41
Q

WBC?

A

5,000-11,000

42
Q

If WBC is <5000

A

C- Critical

43
Q

ANC Normal (Absolute Neutrophil
Count)

A

C - Critical

44
Q

CD4 Count < 200

A

AIDS. =Critical. Neutropenic Precautions

45
Q

High WBC Count(Greather than 11,000)

A

Leukocytosis

46
Q

Low WBC Count

A

Leukopenia
Neutropenia
Agranulocytosis
Immunosuppression
Bone Marrow Suppression

47
Q

Neutropenic Precautions (Low WBC,
Less than 5,000)

A

Strict Handwashing
Shower BID with antimicrobial soap
Avoid Crowds
Private Room
Limit numbers of staff entering room
Limit Visitors for Healthy Adults
No fresh flowers or potted plants
Low Bacteria Diet: No Raw Fruits, Veggies, Salads
No Undercooked meat.
Do not drink water than has been standing longer than 15 minutes
Vital signs (Especially Temperature)
every 4 hours
Check WBC (ANC) Daily
Avoid the use of an indwelling catheter
Do not re-use cups.. must wash between
uses
Use disposable plates, cups, straws,
plastic knife, fork, spoon
Dedicated Items in Room:
Stethoscope
BP Cuff
Thermometer
Gloves
ASSESS FOR INFECTION!!!

48
Q

Platelets (Help Clotting)

A

150-400,000 (Wide Range)

49
Q

Platelets <90,000

A

C= Critical

50
Q

Platelets <40,000

A

D= Deadly Dangerous

51
Q

Bleeding Precautions/Thrombolytic Protocol

A

No unnecessary venipuncture
For injections or IV, Use Small Gauge
Handle Pt Gently, use drawsheet
Use Electric Razor
No toothbrush or flossing
No Hard Foods
Well fit dentures ( No rubbing)
Blow Nose Gently
No rectal temperature, enema, or suppository
No Aspirin
No contact sports
No walking in bare feet
No tight clothes or shoes
Use stool softener. No straining
Notify MD of blood in urine, and stool.

52
Q

RBC’s

A

4-6

53
Q

Abnormal RBC (Not 4-6)

A

B= Be concerned

54
Q

K>6

A

DEADLY DANGEROUS

55
Q

PH<6

A

DEADLY DANGEROUS

56
Q

CO2 in the 60’s

A

DEADLY DANGEROUS

57
Q

Platelets 40,000 or less

A

DEADLY DANGEROUS

58
Q

When should you call a Rapid Response
Team?

A

Symptomatic D’s

59
Q

Absolute Neutrophil count

A

1500-8000mm/3 or 1.5 to 8.0

60
Q

Normal Glasgow Coma Scale

A

15, less than that is not stable

61
Q

Peak flow for Asthma

A

80% or higher is stable and means good
control, 50-79% means caution, and less
then 50 is a medical alert

62
Q

Normal MAP

A

70-105 mm Hg. A MAP <60 will not allow
for adequate perfusion of vital organs

63
Q

Normal Troponin

A

<0.5 for Troponin 1 and <0.1 for Troponin
T

64
Q

Normal Uric Acid Level

A

4.0-8.5

65
Q

Normal Carboxyhemoglobin Level (Carbon monoxide)
2-3% in non smokers and slightly higher
in smokers

A

2-3% in non smokers and slightly higher
in smokers

66
Q

Parkland Formula

A

4mg/ kg of body weight, and first half
within the first 8 hours

67
Q

Normal newborn levels

A

RR 30-60, Glucose <70-100, but > 40 Bo
70/40

NCLEX-LABS (6 decks)

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