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NCLEX Test Strategies
o Read the question and answers carefullydo not jump into conclusions
or make wild guesses.
o Look for keywordsAvoid answers with absolutes like always, never,
all, every, only, must, except, none, or no.
o Dont read into the questionNever assume anything that has not been
specifically mentioned and dont add extra meaning to the question.
o Eliminate answers that are clearly wrong or incorrectto increase your
probability of selecting the correct answer!
o Watch for grammatical inconsistenciesSubjects and verbs should
agree. If the question is an incomplete sentence, the correct answer should
complete the question in a grammatically correct manner.
o Rephrase the questionputting the question into your own words can
pluck the unneeded info and reveal the core of the stem.
o Make an educated guessif you cant make the best answer for a
question after carefully reading it. Choose the answer with the most
information.
Labs and information pertaining to labs to study for NCLEX:
Serum electrolytes

Sodium: 135145 (Hyper/hyponatremia)

Potassium: 3.55.5 (Regular insulin that is given intravenously can reduce serum
potassium levels)
Calcium: 8.510.9
Chloride: 95105
Magnesium: 1.52.5 (A decrease can cause ventricular arrhythmias such as torsades
de pointes)
Phosphorus (phosphate): 2.54.5 (An increase above 4.5 can cause pruritus (itchy
skin)

Vital signs
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Heart rate: 60100 bpm

Respiratory rate: 12-20 rpm
Blood pressure: 110-120/60 mmHg (Baseline: 120/80)
Temperature: 37 C (98.6 F)

Hematology values
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RBCs: 4.55.0 million

WBCs: 5,00010,000
Platelets: 200,000400,000
Hemoglobin (Hgb): 1218
Hematocrit (Hct): 3754

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Chemistry Values
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Specific Gravity: 1.0101.030

LDH: 100-190
Protein: 6.28.1
Albumin: 3.45.0 (Measurement of protein in the bloodstream)
Bilirubin: <1.0
Uric acid: 3.57.5
CPK: 21-232

Hypokalemia
*Even a small decline in potassium levels can cause cardiac events
- A supplemental potassium replacement is used to prevent cardiac arrhythmias
Hyperkalemia
-Patients with hyperkalemia (increased serum potassium) may exhibit bradycardia with widened
QRS waveform on EKG and may develop ventricular fibrillation.
-Can cause progressing muscle weakness, bradycardia, heart block, and can progress to asystole.
Once symptoms begin to show, it is a medical emergency that requires immediate attention.
-Hyperkalemia may cause numbness and tingling of the fingertips and numbness around the
mouth. Nausea, vomiting, and abdominal cramps may also occur with hyperkalemia.
Systemic shock
-The condition of systemic shock from trauma often involves fluid volume depletion from blood
loss. The decreased circulatory blood volume causes an increased heart rate (tachycardia) and
decreased blood pressure (hypotension). The respiratory rate is usually increased to greater than
22 breaths per minute. Patients with shock usually have an altered mental status (AMS) due to
decreased blood volume resulting in decreased oxygen to the brain.
Blood glucose
-Normal blood glucose is 70-110
-Blood glucose should be treated if less than 70. A patient should be given 4 ounces (1/2 cup) of
juice or 8 ounces of nonfat or 1% milk. After the patient finishes the juice, the nurse should
recheck the blood glucose after 15 minutes. If blood glucose remains below 70 mg/dL, the nurse
should administer dextrose 50% per standing orders and report this to the provider. Once blood
glucose returns to normal, the patient should be given a small snack if the meal time is more than
an hour away.
-Routine blood glucose checks use capillary blood and are done at least every morning.
Total cholesterol
-Should be maintained below 200 mg/dL. This will lower the risk of coronary artery disease.
-HDLs should be above 60 mg/dL.
-LDLs should be below 130 mg/dL.
-Triglycerides 30-160 mg/dL
Hypoparathyroidism

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-Causes: a decrease in calcium
an increase in serum phosphorus
-Hypocalemia can cause muscle twitching, spasms, petechiae, and tingling.
-Parathyroid hormone acts to increase serum calcium through the breakdown of bone. Removal
of the parathyroid gland may cause hypocalcemia.
Grave's disease
-Causes hyperthyroidism through the stimulation of TSH receptors. This results in an elevated
T4 level and a diminished TSH level (Due to the negative feedback loop).
-A diminished T4 and elevated TSH occur in hypothyroidism when the thyroid gland is not
producing enough thyroid hormone.
Cirrhosis
-Fluid buildup around the abdominal organs called ascites. In patients with low albumin,
resulting low oncotic pressure allows fluid to leak into the intracellular space.
-Ascites (abdominal fluid retention) is a common occurrence in cirrhosis and liver failure and
can lead to physical discomfort. Patients with ascites should be maintained in an upright position
with the head of the bed elevated to at least 45 degrees. This will reduce shortness of breath from
the abdominal fluid restricting the diaphragm during respiration.
As albumin levels rise, the ascites should resolve, and this is monitored by daily weights and
measurement of abdominal girth.
-Patients with cirrhosis and liver dysfunction often require supplemental protein
because albumin (which makes up 60% of the total protein) is synthesized in the
liver. Albumin levels will rise after approximately three weeks if the supplemental nutrition is
effective.
Jaundice
Characterized by:
1. yellowing of the skin, mucous membranes, and sclera (eyes)
2. Itchy skin (pruritus)
-It is caused by a buildup of bilirubin which is normally filtered by the liver.
Hemolysis
-The destruction of red blood cells. This causes the breakdown of hemoglobin, bilirubin becomes
a byproduct.
This causes an increase of bilirubin in the blood.
Levels greater than 2.5 mg/dL usually cause jaundice.
Hepatic Encephalopathy
-Confusion, personality changes, and asterixis (shaking hands) may be present due to buildup of
ammonia.
-Ammonia is a byproduct of protein catabolism. It is normally converted into urea and excreted,
but in liver disease, ammonia is not converted and serum levels rise.
-A rise in ammonia levels is toxic to the brain and can cause encephalopathy.
Liver disease

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-Causes an elevation in liver enzymes such as alanine transaminase (ALT), aspartate
transaminase (AST) and bilirubin.
-Liver disease will cause a reduction in plasma proteins and albumin production.
-An elevation in bilirubin causes jaundice.
Pancreatitis/Amylase
The normal range for serum amylase is 25-120 U/L.
Amylase is used to diagnose pancreatitis.
If levels are extremely elevated its indicative of acute pancreatitis.
If levels are only slightly elevated its indicative of chronic pancreatitis because of pancreatic
atrophy, causing a decrease in amylase production and storage.
Levels for Kidney Function
BUN: 10-20
Creatinine: 0.5-1.2 (excreted by the kidneys)
*BUN and Creatinine levels may be elevated if renal perfusion is inadequate, kidney disease,
damage, or loss of function (Acute kidney failure)
-Acute kidney injury (AKI) describes the abrupt loss of kidney function resulting in the retention
of urea and other nitrogenous waste products and causing dysregulation of extracellular volume
and electrolytes.
-Informing the doctor quickly of any changes to renal functioning is very important to implement
treatments to prevent long-term or permanent kidney damage.

Normal Ranges
Neutrophils should account for 55-70% of all white blood cells.
*An elevation in neutrophils is indicative of an acute bacterial infection or complications after
surgery.
Lymphocytes 20-40%
*If elevated it usually is indicative of a viral infection
*Pertussis and tuberculosis will elevate leukocytes.
Monocytes 2-8%
*Fungal infections cause elevated monocytes and neutrophils.
Eosinophils 1-4%
*Elevated counts is indicative of a parasitic infection (parasitosis)
*Can also play a role in allergic reactions and asthma.
Basophils 0.5-1%
BNP
- Brain natriuretic peptide is a substance that opposes the action of aldosterone. When the

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ventricular wall is stretched during congestive heart failure, BNP is released. BNP causes
vasorelaxation and inhibition of aldosterone, thereby lowering fluid volume and blood pressure.
Diabetic ketoacidosis (Fruity Breathe)
-Evidenced by the low pH (acidosis) and the low HCO3.
-Bicarb is used to compensate for the buildup of beta-hydroxybutyric and acetoacetic
acids/ketoacids caused by the DKA.
-The PCO2 will be high (if uncompensated) or low (if the lungs are compensating with classic
Kussmual respirations to blow off CO2).
Diabetes mellitus and DKA
-Patients with type 1 diabetes mellitus may experience diabetic ketoacidosis (DKA) when there
is insufficient insulin to transport glucose into cells for energy.
-This condition can lead to fluid volume depletion (dehydration) due to polyuria (excess
urination) as the kidneys attempt to filter glucose from the bloodstream.
-Cells are unable to get glucose for energy production due to lack of insulin. This causes the
body to break down fat and protein for energy. The by-products of this process are ketones
which make the blood acidic.
-Patients with type 2 diabetes mellitus still produce some insulin in the pancreas so DKA
does not occur in these patients.
Administering Insulin
-When a diabetic patient with elevated blood glucose requires insulin, the nurse
must always have the insulin dose verified by a second nurse. Insulin can cause severe harm if
administered improperly.
***Never give insulin as an IM injection because this will interfere with the expected onset,
peak, and duration times of the insulin. Insulin should be given subcutaneously unless otherwise
ordered by the doctor.
***A patient with hyperglycemia (high blood glucose) should not be given extra sugar intake
while the blood glucose is high or the insulin will be less effective in reducing overall blood
glucose.
Dehydration:
**Increased hematocrit due to low fluid volume- (portion of total blood volume of red blood
cells)
Increased sodium- due to low fluid volume
Increased hemoglobin- protein molecule in RBCs that carry oxygen
Increased chloride
Chronic renal failure
-Chronic renal failure can cause decreased hemoglobin formation due to insufficient
erythropoietin production.
-Carbohydrate intake is encouraged to help provide adequate energy for body functions.
-Sodium bicarbonate helps prevent metabolic acidosis

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Acute renal failure
-May cause elevation of serum electrolytes if the kidneys are unable to produce enough urine to
filter out excess potassium and sodium
Hyponatremia (decreased serum sodium level)
-Occurs frequently in patients with acute renal failure because these patients often have
decreased urine output (oliguria) causing dilute blood associated with fluid retention.
Hyponatremia can be treated with fluid restriction. If this alone does not resolve the
hyponatremia, a hypertonic 3% saline solution can be given intravenously for sodium
replacement.
Implementing neutropenic precautions
-Neutropenia refers to count being < 1000/mm
-A neutrophil count of less than 500/mm indicates a severe risk of infection.
-Restricting fresh, uncooked fruits and vegetables from the diet and removing flowers and plants
from the room is recommended due to the risk of microbial contamination.
-Visitors with any potentially communicable disease should be screened for the presence of
infection and must not be allowed near the patient.
-The client should have a single room with positive air pressure (air pressure higher than the
surrounding rooms) to prevent potentially contaminated air from coming in the client's room.
Sepsis
Lactate normal range: 0.5 to 2.2
Lactate (or lactic acid) elevation is indicative to sepsis or tissue ischemia due to low tissue
perfusion and oxygenation. This causes the creation of energy through anaerobic metabolism,
which forms lactic acid as a waste product.
*Can cause metabolic acidosis
Lumbar puncture
-Lumbar puncture places the patient at high risk for complications, one of which is a subdural or
epidural hematoma. Bleeding in the subdural or epidural space mechanically compresses the
spinal cord, affecting sensation and movement. Compression of lumbar spinal roots may cause
cauda equina syndrome and lower extremity paresis. Deficits progress over minutes to hours.
-Prompt intervention is critical, so this finding should be reported to the physician immediately.
Myocardial infarction (MI) (Heart Attack)
-Troponin-I and CK-MB levels are elevated
-Troponin-I level greater than 0.03 ng/mL is indicative of a myocardial damage.
-Troponin-I is more specific for cardiac muscle injury than CK-MB and elevates 4-6 hours after
infarction.
***CK-MB and troponin are cardiac muscle-specific enzymes. Troponin levels will remain
elevated in the presence of cardiac muscle damage for up to 15 days after the injury. Troponin
levels will be less than 0.01 ng/mL in patients without cardiac injury.

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CHF (Congestive heart failure)

-People with a history of myocardial infarction are at an increased risk of developing congestive
heart failure (CHF). This is due to damage to the heart muscle (myocardium) that occurs from
ischemia (decreased oxygen) during a heart attack (MI). In this condition, the heart muscle is
weakened and does not pump efficiently.
-Excess fluid builds up in the heart chambers, which then backs up into the lungs, causing
shortness of breath.
-This process causes a backup of all circulatory blood and fluid resulting in excess fluid volume.
This excess fluid volume causes an increase in weight. People with CHF need to manage this
condition at home with daily weight measurements and report a weight gain of 2 or more pounds
in 24 hours or 5 pounds or more in 1 week.
-People with congestive heart failure (CHF) have difficulty with fluid volume excess causing
edema (swelling) and shortness of breath. Water follows sodium, so these patients will be on a
low sodium diet with less than 2 grams of sodium in 24 hours daily to prevent fluid retention and
edema (excess fluid accumulation). Fluid intake will be restricted in these patients so that the
diuretics used to expel excess fluid will be more effective. CHF patients also need to limit
overall fluid intake to prevent over hydration which can contribute to fluid retention, edema, and
shortness of breath.
***Antacids with bicarbonate should not be taken regularly because they can raise sodium
levels, which is important for anyone on sodium restrictions.
Right-sided heart failure
-In a patient with right-sided heart failure, the edema is seen peripherally, in the extremities and
organs (hepatomegaly). These right-sided heart failure patients often have lower extremity
edema. This swelling can make the legs sore and tender. The nurse can assist the patient to keep
the legs elevated to reduce swelling.
If the patient is wearing compression socks, these should be changed daily but kept in place to
help reduce swelling.
Left-sided heart failure
-In left-sided heart failure, the fluid backs up into the lungs, causing impaired gas exchange and
breathing difficulties. In left-sided heart failure, the legs should not be elevated, to avoid fluid
backing up into the lungs.
DVT
-D-Dimer is used to help diagnose a DVT.
-D-dimer is a fibrin degradation product. These products increase during a thrombotic event.
-An elevated D-dimer is indicative of a DVT, but an ultrasound is needed to confirm the
presence of a DVT.
Skeletal muscle damage
-Elevated CK-MM levels (M) - muscle

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(B)- Brain
Glycosylated hemoglobin (Hgb A1C)
Normal value: 7% or below
HgbA1c monitors long-term control of blood glucose levels.
HgbA1c measures amount of glucose molecules that have reacted with a red blood cell over the
lifespan of the cell (120 days).
HgbA1c levels are done 2-4 times annually.
Hypervolemia
excess fluid in the intravascular space.
A bounding pulse, rapid heart rate and high blood pressure would be noted.
***If untreated, symptoms would progress to pink frothy sputum as the pressure increases in the
lungs, resulting in pulmonary edema.
Hypovolemia
A weak, thread pulse, rapid heart rate, and low blood pressure would be seen
Iron Supplements
-Patients with reduced hemoglobin and hematocrit who are started on iron supplements should
be given instructions to know how to properly take these supplements to increase absorption so
that more red blood cells are produced.
-Ferrous sulfate (iron) supplements should be taken with orange juice or vitamin C to increase
absorption.
-Iron supplements may cause constipation and dark brown or black stools.
-Iron supplements should not be taken with milk or calcium as this prevents absorption in the GI
tract.
aPTT
Reference range: 30-40 seconds
Ratio: 1.5-2.5
Therapeutic level: 45-100 seconds (DVT prevention)
PT
Reference range: 11-12.5 seconds.
For patients on warfarin, the therapeutic level is 1.5-to-2 times the normal level
INR
Reference range is 0.8-1.1.
Patients requiring anticoagulation for atrial fibrillation have a target INR range of 2.0-3.0.
Coumadin
-Vitamin K is the antidote for Coumadin.
-Green leafy vegetables are a good source of vitamin K and can reduce the effects of Coumadin
when eaten.

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-Patients who require Coumadin to thin the blood may need the effect to be counteracted if the
blood is too thin prior to surgical procedures.
Head trauma
-Secondary diabetes insipidus may occur as a result of trauma or a pathologic condition of the
posterior pituitary that causes a decrease in the secretion of anti-diuretic hormone (ADH).
-Decreased amounts of ADH will cause increased water loss through the urine with large
amounts of very dilute urine and increased thirst related to the correlated dehydration that occurs.
Syncope
Temporary loss of consciousness cause by a fall in blood pressure
-Patients with symptomatic hypotension related to dehydration and who have complaints of
dizziness and lightheadedness should be placed supine with the feet elevated higher than the
head. This position allows more blood to remain in the upper body allows more oxygen to reach
the brain.
-This position will help reduce symptoms of dizziness and lightheadedness and is the first
intervention that should be used to relieve symptoms.
Thyroidectomy
A patient who has had a thyroidectomy has also had the parathyroid glands removed. The
parathyroid glands are responsible for the calcium and phosphate levels in the blood. These
patients will require regular monitoring of calcium and phosphate levels.
*Hypocalcemia may cause tetany (painful contractions of muscles) and cardiac dysrhythmias.

-Trousseau sign of latent tetany is sign seen in patients with hypocalcemia. This sign is believed
to be more sensitive an indicator (94%) than the Chvostek sign (29%). To see the sign, you must
inflate a blood pressure cuff for a couple minutes to occlude the brachial artery. In the absence of
blood flow, the patient's hypocalcemia and resulting neuromuscular irritability will induce the
spasm of the hand and forearm.
Coronary bypass graft surgery
-Blood loss occurs with volume depletion during heart surgery. After surgery patients need to
maintain a systolic blood pressure of greater than 90 for adequate perfusion of the myocardial
tissue through the new bypass grafts and to prevent graft collapse.
-Serum hemoglobin of less than 8.0 and hematocrit of less than 24.0 usually require transfusion
of packed red blood cells. This is even more crucial in patients with coronary bypass grafts so the
new graft sites will receive adequate oxygen supply.
Transfusion
-When a patient requires a transfusion of a blood product, the nurse must always verify that it is
the correct product and the correct patient with a second nurse at the patient's bedside prior to
administering it. The nurse should instruct the patient on possible side effects and what
symptoms to report. Vital signs including temperature and blood pressure should be assessed
prior to administration and 15 minutes after blood product is initiated.

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ABGs
pH:
CO2:
PaCO2:
HCO3:
O2 sat:

7.35-7.45 (Determines the acidity or alkalinity of the blood)

35-45 (Respiratory)
80-100 (Respiratory)
22-26 (Metabolic)
95-100%
90% is okay with COPD

ROME:
Respiratory Opposite
When pH is up, PaCO2 is down = Alkalosis
When pH is down, PaCO2 is up = Acidosis
Metabolic Equal
When pH is up, HCO3 is up = Alkalosis
When pH is down, HCO3 is down = Acidosis
Metabolic Acidosis: (Metabolic equal)
-Caused by loss of bicarb or a buildup of acids- not caused by respiration.
Ex: lactic acidosis, renal failure, ketones, or ammonium intoxication, emesis, diuretics,
diarrhea
-HCO3 decreases, pH decreases
-Compensation- hyperventilation to eliminate CO2
* The rapid, deep breathing of Kaussmaul's respirations are a compensatory mechanism to try to
eliminate acid in the form of carbon dioxide when the body is in metabolic acidosis
Respiratory Acidosis: (Respiratory opposite)
-Respiratory system is the cause Ex. Hyperventilation
-Increase in PCO2, decrease in pH
-Compensation- kidneys reabsorb Bicarb (HCO3)

Respiratory Alkalosis:
-Caused by excessive ventilation
-Decrease in PCO2, increase in pH
-Compensation - Kidneys excrete HCO3
*Hyperventilation is an increase in respiratory rate and/or volume which cause a decrease in
PCO2. This in turn raises the pH to cause respiratory alkalosis.
Metabolic Alkalosis
-Acid (H+) lost from emesis, diuretics. Retention of HCO3 from medications,
hyperaldosteronism
-Increase in HCO3, Increase in pH

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-Compensation - Respiratory centers are not stimulated; this leads to hypoventilation and
CO2 retention.
Determine compensation
Is the ABG is Compensated, Partially Compensated, or Uncompensated.
If pH is NORMAL, PaCO2 and HCO3 are both ABNORMAL = Compensated
If pH is ABNORMAL, PaCO2 and HCO3 are both ABNORMAL = Partially Compensated
If pH is ABNORMAL, PaCO2 or HCO3 is ABNORMAL = Uncompensated
*Hyperaldosteronism increases renal loss of hydrogen ions and increases sodium-hydrogen
exchange in the kidney. Sodium retention causes excess fluid volume and the hydrogen ion loss
leads to metabolic alkalosis.
*Gastric lavage and persistent vomiting cause removal of hydrochloric acid from the stomach,
which may lead to metabolic alkalosis.
Example: pH: 7.26, paCO2: 32, HCO3: 18
Metabolic Acidosis, Partially Compensated

Example: pH: 7.44, PaCO2: 30, HCO3: 21

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Example: pH: 7.10, paCO2: 40, HCO3: 18

PaO2- partial pressure of arterial oxygen

-Depending on oxygen demands at tissue level
curve shifts rightwards (low saturation of PaO2)
curve shifts leftwards (higher saturation of PaO2)
Right- needs more oxygen: Heat (hot weather)
Exercise
Acidotic (Low pH)
Hypercarbia (high CO2 in blood)
Releases oxygen
Left- activity is minimal: Cold weather
During rest
Tissues are cold
Alkalotic (high pH)
Hypocarbia
Carbon Monoxide poisoning
Holds onto oxygen
*Only 2-3 % of oxygen goes to plasma; the rest attaches to hemoglobin molecules in
RBCs
- If PaO2 is higher- more attaches (it is more readily)
-If PaO2 is lower- less attaches

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Common Signs and Symptoms

o Pulmonary Tuberculosis (PTB)low-grade afternoon fever.
o Pneumoniarust-colored sputum.
o Asthmawheezing on expiration.
o Emphysemabarrel chest.
o Kawasaki Syndromestrawberry tongue.
o Pernicious Anemiared beefy tongue.
o Down syndromeprotruding tongue.
o Cholerarice-watery stool and washer womans hands (wrinkled hands from
dehydration).
o Malariastepladder like fever with chills.
o Typhoidrose spots in the abdomen.
o Denguefever, rash, and headache. Positive Hermans sign.
o Diphtheriapseudo membrane formation.
o MeaslesKopliks spots (clustered white lesions on buccal mucosa).
o Systemic Lupus Erythematosusbutterfly rash.
o Leprosyleonine facies (thickened folded facial skin).
o Bulimiachipmunk facies (parotid gland swelling).
o Appendicitisrebound tenderness at McBurneys point. Rovsings sign (palpation
of LLQ elicits pain in RLQ). Psoas sign (pain from flexing the thigh to the hip).
o MeningitisKernigs sign (stiffness of hamstrings causing inability to straighten the
leg when the hip is flexed to 90 degrees), Brudzinskis sign (forced flexion of the
neck elicits a reflex flexion of the hips).
o Tetanyhypocalcemia, [+] Trousseaus sign; Chvostek sign.
o Tetanus Risus sardonicus or rictus grin.
o PancreatitisCullens sign (ecchymosis of the umbilicus), Grey Turners sign
(bruising of the flank).
o Pyloric Stenosisolive like mass.
o Patent Ductus Arteriosuswashing machine-like murmur.
o Addisons diseasebronze like skin pigmentation.
o Cushings syndromemoon face appearance and buffalo hump.
o Graves Disease (Hyperthyroidism)Exophthalmos (bulging of the eye out of the
orbit).
o IntussusceptionSausage-shaped mass.
o Multiple SclerosisCharcots Triad: nystagmus, intention tremor, and dysarthria.
o Myasthenia Gravisdescending muscle weakness, ptosis (drooping of eyelids).
o Guillain-Barre Syndromeascending muscles weakness.
o Deep vein thrombosis (DVT)Homans Sign.
o Anginacrushing, stabbing pain relieved by NTG.
o Myocardial Infarction (MI)crushing, stabbing pain radiating to left shoulder,
neck, and arms. Unrelieved by NTG.
o Parkinsons diseasepill-rolling tremors.

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o Cytomegalovirus (CMV) infectionOwls eye appearance of cells (huge nucleus in
cells).
o Glaucomatunnel vision.
o Retinal Detachmentflashes of light, shadow with curtain across vision.
o Basilar Skull FractureRaccoon eyes (periorbital ecchymosis) and Battles sign
(mastoid ecchymosis).
o Buergers Diseaseintermittent claudication (pain at buttocks or legs from poor
circulation resulting in impaired walking).
o Diabetic Ketoacidosisacetone breathe.
o Pregnancy Induced Hypertension (PIH)proteinuria, hypertension, edema.
o Diabetes Mellituspolydipsia, polyphagia, polyuria.
o Gastroesophageal Reflux Disease (GERD)heartburn.
o Hirschsprungs Disease (Toxic Megacolon)ribbon-like stool.

Therapeutic Drug Levels

o Carbamazepine (Tegretol): 410 mcg/ml
o Digoxin (Lanoxin): 0.82.0 ng/ml
o Gentamycin (Garamycin): 510 mcg/ml (peak), <2.0 mcg/ml (valley)
o Lithium (Eskalith): 81.5 mEq/L
o Phenobarbital (Solfoton): 1540 mcg/mL
o Phenytoin (Dilantin): 1020 mcg/dL
o Theophylline (Aminophylline): 1020 mcg/dL
o Tobramycin (Tobrex): 510 mcg/mL (peak), 0.52.0 mcg/mL (valley)
o Valproic Acid (Depakene): 50100 mcg/ml
o Vancomycin (Vancocin): 2040 mcg/ml (peak), 5 to 15 mcg/ml (trough)
Anticoagulant therapy
o Sodium warfarin (Coumadin) PT: 1012 seconds (control). The
antidote is Vitamin K.
o INR (Coumadin): 0.91.2
o Heparin PTT: 3045 seconds (control). The antidote is protamine
sulfate.
o APTT: 331.9 seconds
o Fibrinogen level: 203377 mg/dL
Conversions
o
o
o
o
o
o
o
o
o
o

1 teaspoon (t) = 5 ml
1 tablespoon (T) = 3 t = 15 ml
1 oz. = 30 ml
1 cup = 8 oz.
1 quart = 2 pints
1 pint = 2 cups
1 grain (gr) = 60 mg
1 gram (g) = 1,000 mg
1 kilogram (kg) = 2.2 lbs.
1 lb. = 16 oz.

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o
o

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

Maternity Normal Values

o Fetal Heart Rate: 120160 bpm
o Variability: 610 bpm
o Amniotic fluid: 5001200 ml
o Contractions: 25 minutes apart with duration of < 90 seconds and
intensity of <100
APGAR Scoring:
Appearance, Pulses, Grimace, Activity, Reflex Irritability.
Done at 1 and 5 minutes with a score of 0 for absent, 1 for decreased, and 2 for strongly positive.
Scores 7 and above are generally normal, 4 to 6 fairly low and 3 and below are generally
regarded as critically low.
AVA: The umbilical cord has two arteries and one vein.

STOPTreatment for maternal hypotension after an epidural anesthesia:

o Stop infusion of Pitocin.
o Turn the client on her left side.
o Administer oxygen.
o If hypovolemia is present, push IV fluids.
Pregnancy Category of Drugs
o Category ANo risk in controlled human studies
o Category BNo risk in other studies. Examples: Amoxicillin, Cefotaxime.
o Category CRisk not ruled out. Examples: Rifampicin (Rifampin),
Theophylline (Theolair).
o Category DPositive evidence of risk. Examples: Phenytoin, Tetracycline.
o Category XContraindicated in Pregnancy. Examples: Isotretinoin
(Accutane), Thalidomide (Immunoprin), etc.
o Pregnancy Category NNot yet classified

Medication Classifications
o Antacidsreduces hydrochloric acid in the stomach.
o Antianemicsincreases blood cell production.
o Anticholinergicsdecreases oral secretions.
o Anticoagulantsprevents clot formation,
o Anticonvulsantsused for management of seizures and/or bipolar
disorders.
o Antidiarrhealsdecreases gastric motility and reduce water in bowel.
o Antihistaminesblock the release of histamine.
o Antihypertensiveslower blood pressure and increases blood flow.
o Anti-infectivesused for the treatment of infections,
o Bronchodilatorsdilates large air passages in asthma or lung diseases
(e.g., COPD).

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o
o
o
o
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Diureticsdecreases water/sodium from the Loop of Henle.

Laxativespromotes the passage of stool.
Mioticsconstricts the pupils.
Mydriaticsdilates the pupils.
Narcotics/analgesicsrelieves moderate to severe pain.

Rules of nines for (TBSA) for burns

o Head and neck: 9%
o Upper limbs: 18% (9% each)
o Trunk: 36%
o Legs: 36% (18% each)
o Genitalia: 1%
Medications
o Digoxin (Lanoxin)Assess pulses for a full minute, if less than 60 bpm
hold dose. Check digitalis and potassium levels.
o Aluminum Hydroxide (Amphojel)Treatment of GERD and kidney
stones. WOF constipation.
o Hydroxyzine (Vistaril)Treatment of anxiety and itching. WOF dry
mouth.
o Midazolam (Versed)given for conscious sedation. Watch out for
(WOF) respiratory depression and hypotension.
o Amiodarone (Cordarone)WOF diaphoresis, dyspnea, lethargy. Take
missed dose any time in the day or to skip it entirely. Do not take double
dose.
o Warfarin (Coumadin)WOF for signs of bleeding, diarrhea, fever, or
rash. Stress importance of complying with prescribed dosage and follow-up
appointments.
o Methylphenidate (Ritalin)Treatment of ADHD. Assess for heart related
side-effects and reported immediately. Child may need a drug holiday
because the drug stunts growth.
o DopamineTreatment of hypotension, shock, and low cardiac output.
Monitor ECG for arrhythmias and blood pressure.
o Rifampicincauses red-orange tears and urine.
o Ethambutolcauses problems with vision, liver problem.
o Isoniazidcan cause peripheral neuritis, take vitamin B6 to counter.
Developmental Milestones
o 23 months: able to turn head up, and can turn side to side. Makes cooing
or gurgling noises and can turn head to sound.
o 45 months: grasps, switch and roll over tummy to back. Can babble and
can mimic sounds.
o 67 months: sits at 6 and waves bye-bye. Can recognize familiar faces
and knows if someone is a stranger. Passes things back and forth between
hands.
o 89 months: stands straight at eight, has favorite toy, plays peek-a-boo.
o 1011 months: belly to butt.

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o

1213 months: twelve and up, drinks from a cup. Cries when parents
leave, uses furniture to cruise.

Cultural Considerations
o African AmericansMay believe that illness is caused by supernatural
causes and seek advice and remedies form faith healers; they are family
oriented; have higher incidence of high blood pressure and obesity; high
incidence of lactose intolerance with difficulty digesting milk and milk
products.
o Arab AmericansMay remain silent about health problems such as STIs,
substance abuse, and mental illness; a devout Muslim may interpret illness
as the will of Allah, a test of faith; may rely on ritual cures or alternative
therapies before seeking help from health care provider; after death, the
family may want to prepare the body by washing and wrapping the body in
unsewn white cloth; postmortem examinations are discouraged unless
required by law. May avoid pork and alcohol if Muslim. Islamic patients
observe month long fast of Ramadan (begins approximately mid-October);
people suffering from chronic illnesses, pregnant women, breast-feeding, or
menstruating dont fast. Females avoid eye contact with males; use samesex family members as interpreters.
o Asian AmericansMay value ability to endure pain and grief with silent
stoicism; typically family oriented; extended family should be involved in
care of dying patient; believes in hot-cold yin/yang often involved;
sodium intake is generally high because of salted and dried foods; may
believe prolonged eye contact is rude and an invasion of privacy; may not
without necessarily understanding; may prefer to maintain a comfortable
physical distance between the patient and the health care provider.
o Latino AmericansMay view illness as a sign of weakness, punishment
for evil doing; may consult with a curandero or voodoo priest; family
members are typically involved in all aspects of decision making such as
terminal illness; may see no reason to submit to mammograms or
vaccinations.
o Native AmericansMay turn to a medicine man to determine the true
cause of an illness; may value the ability to endure pain or grief with silent
stoicism; diet may be deficient in vitamin D and calcium because many
suffer from lactose intolerance or dont drink milk; obesity and diabetes are
major health concerns; may divert eyes to the floor when they are praying
or paying attention.
o Western CultureMay value technology almost exclusively in the
struggle to conquer diseases; health is understood to be the absence,
minimization, or control of disease process; eating utensils usually consists
of knife, fork, and spoon; three daily meals is typical.

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Common Diets
o
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Acute Renal Diseaseprotein-restricted, high-calorie, fluid-controlled,

sodium and potassium controlled.
Addisons diseaseincreased sodium, low potassium diet.
ADHD and Bipolarhigh-calorie and provide finger foods.
Burnshigh protein, high caloric, increases in Vitamin C.
Cancerhigh-calorie, high-protein.
Celiac Diseasegluten-free diet (no BROW: barley, rye, oat, and wheat).
Chronic Renal Diseaseprotein-restricted, low-sodium, fluid-restricted,
potassium-restricted, phosphorus-restricted.
Cirrhosis (stable)normal protein
Cirrhosis with hepatic insufficiencyrestrict protein, fluids, and sodium.
Constipationhigh-fiber, increased fluids
COPDsoft, high-calorie, low-carbohydrate, high-fat, small frequent
feedings
Cystic Fibrosisincrease in fluids.
Diarrhealiquid, low-fiber, regular, fluid and electrolyte replacement
Gallbladder diseaseslow-fat, calorie-restricted, regular
Gastritislow-fiber, bland diet
Hepatitisregular, high-calorie, high-protein
Hyperlipidemiasfat-controlled, calorie-restricted
Hypertension, heart failure, CADlow-sodium, calorie-restricted, fatcontrolled
Kidney Stonesincreased fluid intake, calcium-controlled, low-oxalate
Nephrotic Syndromesodium-restricted, high-calorie, high-protein,
potassium-restricted.
Obesity, overweightcalorie-restricted, high-fiver
Pancreatitislow-fat, regular, small frequent feedings; tube feeding or
total parenteral nutrition.
Peptic ulcerbland diet
Pernicious Anemiaincrease Vitamin B12 (Cobalamin), found in high
amounts on shellfish, beef liver, and fish.
Sickle Cell Anemiaincrease fluids to maintain hydration since sickling
increases when patients become dehydrated.
Strokemechanical soft, regular, or tube-feeding.
Underweighthigh-calorie, high protein
Vomitingfluid and electrolyte replacement

Positioning Clients
o Asthmaorthopneic position where patient is sitting up and bent forward
with arms supported on a table or chair arms.
o Post Bronchoscopyflat on bed with head hyperextended.
o Cerebral Aneurysmhigh Fowlers.

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o
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o
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Hemorrhagic Stroke: HOV elevated 30 degrees to reduce ICP and

facilitate venous drainage.
Ischemic Stroke: HOB flat.
Cardiac Catheterizationkeep site extended.
Epistaxislean forward.
Above Knee Amputationelevate for first 24 hours on pillow, position
on prone daily for hip extension.
Below Knee Amputationfoot of bed elevated for first 24 hours, position
prone daily for hip extension.
Tube feeding for patients with decreased LOCposition patient on right
side to promote emptying of the stomach with HOB elevated to prevent
aspiration.
Air/Pulmonary embolismturn patient to left side and lower HOB.
Postural DrainageLung segment to be drained should be in the
uppermost position to allow gravity to work.
Post Lumbar puncturepatient should lie flat in supine to prevent
headache and leaking of CSF.
Continuous Bladder Irrigation (CBI)catheter should be taped to thigh
so legs should be kept straight.
After myringotomyposition on the side of affected ear after surgery
(allows drainage of secretion).
Post cataract surgerypatient will sleep on unaffected side with a night
shield for 1-4 weeks.
Detached retinaarea of detachment should be in the dependent position.
Post thyroidectomylow or semi-Fowlers, support head, neck and
shoulders.
Thoracentesissitting on the side of the bed and leaning over the table
(during procedure); affected side up (after procedure).
Spina Bifida position infant on prone so that sac does not rupture.
Bucks Tractionelevate foot of bed for counter-traction.
Post Total Hip Replacementdont sleep on operated side, dont flex hip
more than 45-60 degrees, dont elevate HOB more than 45 degrees.
Maintain hip abduction by separating thighs with pillows.
Prolapsed cordknee-chest position or Trendelenburg.
Cleft-lipposition on back or in infant seat to prevent trauma to the suture
line. While feeding, hold in upright position.
Cleft-palateprone.
Hemorrhoidectomyassist to lateral position.
Hiatal Herniaupright position.
Preventing Dumping Syndromeeat in reclining position, lie down after
meals for 20-30 minutes (also restrict fluids during meals, low fiber diet,
and small frequent meals).
Enema Administrationposition patient in left-side lying (Sims
position) with knees flexed.
Post supratentorial surgery (incision behind hairline)elevate HOB
30-45 degrees.

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o
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Post infratentorial surgery (incision at nape of neck)position patient

flat and lateral on either side.
Increased ICPhigh Fowlers.
Laminectomyback as straight as possible; log roll to move and sand bag
on sides.
Spinal Cord Injuryimmobilize on spine board, with head in neutral
position. Immobilize head with padded C-collar; maintain traction and
alignment of head manually. Log roll client and do not allow client to twist
or bend.
Liver Biopsyright side lying with pillow or small towel under puncture
site for at least 3 hours.
Paracentesisflat on bed or sitting.
Intestinal Tubesplace patient on right side to facilitate passage into
duodenum.
Nasogastric Tubeselevate HOB 30 degrees to prevent aspiration.
Maintain elevation for continuous feeding or 1hour after intermittent
feedings.
Pelvic Examlithotomy position.
Rectal Examknee-chest position, Sims, or dorsal recumbent.
During internal radiationpatient should be on bed rest while implant is
in place.
Autonomic Dysreflexiaplace client in sitting position (elevate HOB)
first before any other implementation.
Shockbed rest with extremities elevated 20 degrees, knees straight, head
slightly elevated (modified Trendelenburg).
Head Injuryelevate HOB 30 degrees to decrease intracranial pressure.
Peritoneal Dialysis when outflow is inadequateturn patient side to side
before checking for kinks in the tubing.
Myelogram
Water-based dyesemi Fowlers for at least 8 hours.
Oil-based dyeflat on bed for at least 6-8 hours to prevent
leakage of CSF.
Air dyeTrendelenburg.

Miscellaneous Study material

o Delegate sterile skills (e.g., dressing change) to the RN or LPN.
o Where non-skilled care is required, delegate the stable client to the nursing
assistant.
o Assign the most critical client to the RN.
o Clients who are being discharged should have final assessments done by
the RN.
o The Licensed Practical Nurse (LPN) can monitor clients with IV therapy,
insert urinary catheters, feeding tubes, and apply restraints.
o Assessment, teaching, medication administration, evaluation, unstable
patients cannot be delegated to an unlicensed assistive personnel.
o Weight is the best indicator of dehydration.

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o
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When patient is in distress, administration of medication is rarely the

best choice.
Always check for allergies before administering antibiotics.
Neutropenic patients should not receive vaccines, fresh fruits, or flowers.
Nitroglycerine patch is administered up to three times with intervals of
five minutes.
Morphine is contraindicated in pancreatitis because it causes spasms of the
Sphincter of Oddi. Demerol should be given.
Never give potassium (K+) in IV push.
Infants born to an HIV-positive mother should receive all
immunizations of schedule.
Gravida is the number of pregnancies a woman has had, regardless of
outcome.
Para is the number of pregnancies that reached viability, regardless of
whether the fetus was delivered alive or stillborn. A fetus is considered
viable at 20 weeks gestation.
Lochia rubra is the vaginal discharge of almost pure blood that occurs
during the first few days after childbirth.
Lochia serosa is the serous vaginal discharge that occurs 4 to 7 days after
childbirth.
Lochia alba is the vaginal discharge of decreased blood and increased
leukocytes thats the final stage of lochia. It occurs 7 to 10 days after
childbirth.
In the event of fire, the acronym most often used is RACE. (R) Remove
the patient. (A) Activate the alarm. (C) Attempt to contain the fire by
closing the door. (E) Extinguish the fire if it can be done safely.
Before signing an informed consent form, the patient should know
whether other treatment options are available and should understand what
will occur during the preoperative, intraoperative, and postoperative
phases; the risks involved; and the possible complications. The patient
should also have a general idea of the time required from surgery to
recovery. In addition, he should have an opportunity to ask questions.
The first nursing intervention in a quadriplegic client who is
experiencing autonomic dysreflexia is to elevate his head as high as
possible.
Usually, patients who have the same infection and are in strict isolation
can share a room.
Veracity is truth and is an essential component of a therapeutic relationship
between a health care provider and his patient.
Beneficence is the duty to do no harm and the duty to do good. Theres an
obligation in patient care to do no harm and an equal obligation to assist the
patient.
Nonmaleficence is the duty to do no harm.
Tyramine-rich food, such as aged cheese, chicken liver, avocados, bananas,
meat tenderizer, salami, bologna, Chianti wine, and beer may cause severe
hypertension in a patient who takes a monoamine oxidase inhibitor.

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o
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Projection is the unconscious assigning of a thought, feeling, or action to

someone or something else.
Sublimation is the channeling of unacceptable impulses into socially
acceptable behavior.
Repression is an unconscious defense mechanism whereby unacceptable
or painful thoughts, impulses, memories, or feelings are pushed from the
consciousness or forgotten.
People with obsessive-compulsive disorder realize that their behavior is
unreasonable, but are powerless to control it.
A significant toxic risk associated with clozapine (Clozaril)
administration is blood dyscrasia.
Adverse effects of haloperidol (Haldol) administration include drowsiness;
insomnia; weakness; headache; and extrapyramidal symptoms, such as
akathisia, tardive dyskinesia, and dystonia.
Hypervigilance and dj vu are signs of posttraumatic stress disorder
(PTSD).

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Study Tips
1. Never choose an answer that leaves the patient. Always provide safety.
2. Dont do nothing. Because you always have to do something.
3. Dont read into the question. Never assume anything that has not been specifically
mentioned and dont add extra meaning to the question.
4. Dont pass the buck. Never choose an answer that passes work off to anyone else.
5. If you see an option you have never heard of, do not choose it. Its like a signal from your
brain that that is not the correct answer.
6. When choosing which patient to see first, choose the patient who is the most
unstable. Patients who are most likely to perish, most critical, or will suffer further injury
without immediate action should be prioritized first.
7. Always assume the NCLEX hospital has unlimited staff, equipment, and
resources. Know that health care facilities in the NCLEX are always ideal.
8. Restraints are always the last option and are almost always the wrong answer.
9. Choose the least invasive choice first. Issues concerning airway, breathing, or circulation
should be addressed first, then move to choose the least invasive procedures (e.g., change of
position, therapeutic communication with the patient).
10. Never choose an answer that delays treatment. These distractors do not coincide to safe
and effective nursing care.
11. Assess the client first, before implementing a treatment. If theres a choice that pertains to
assessment of the patient, choose that answer.
12. Find a commonality between the choices if you encounter a question which you are
unfamiliar with. If two or more answers are alike, choose the option that is different.
13. If the question includes the words severe or acute when referring to something such as
pain, choose the answer that fixes that specific problem.
14. If the question is about endorsement, always report anything new or different to the next
shift.
15. In general, put clients with the same or similar diagnoses in the same room.

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16. After comprehending the question, decide what is the problem then pick answer that you
can do as a nurse to solve it.
17. Select an answer that is focused on the client.
18. Answer select all that apply (SATA) questions as a true or false. Go down the list of
choices one by one and ask yourself if the choice answers the question.
19. Rephrase the question. Putting the question in your own words can pluck the necessary info
to reveal the core of the stem.
20. Make educated guesses. If you cant make the best answer for a particular question, give it a
guess. The board exams is not a right minus wrong type. It is important for you to answer
every question even if you have to guess.
***Heres the secret to SATA questions:
Theyre actually a form of true or false type of questions! Therefore you proceed to answer
each option by responding either with a yes or a no, if it applies, or does not apply to
what the question is asking. Go down the list one by one and ask yourself if its a correct answer,
then look at the next choice and do the same thing***
A. Dont group choices
Treat each choice as a possible answer separate to the other choices. Dont group or link the
choices to one another and should not be answered as a group.
B. Pay attention to the options
Watch out for absolutes or extremes (e.g., at all times, all the time, complete restriction) as these
are probably wrong choices. If you cannot recall the information or if it doesnt make sense, its
probably wrong.
C. Dont over think
After youve chosen your answers by following step (tackle one by one), do not go back to
change your answer. Most SATA questions are not on the application or analysis level type of
questions, so it usually does not need you to factor in anything and modify your response. Do not
change your answer unless there is something really obvious youve overlooked (i.e., the
question looks for a negative response).
D. Minimum of two
According to the NCSBN site, there will always be more than one correct answer so a minimum
of two correct options. Its also rare to have all choices correct but it can technically
happen. NCSBN requires the candidate to utilize their comprehensive knowledge to determine
the appropriate amount of applicable maximum correct answers to each item.
E. Move on
If you tried the tips above and still cant find the answer, youre just wasting time and move on.
Dont let your momentum stop just because of a single question.

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Heres an example to try yourself:

Question: A nurse is caring for a pregnant client with severe preeclampsia who is receiving
IV magnesium sulfate. Select all nursing interventions that apply in the care for the client.
1. Monitor maternal vital signs every 2 hours
2. Notify the physician if respirations are less than 18 per minute.
3. Monitor renal function and cardiac function closely
4. Keep calcium gluconate on hand in case of a magnesium sulfate overdose
5. Monitor deep tendon reflexes hourly
6. Monitor I and Os hourly
7. Notify the physician if urinary output is less than 30 ml per hour.
Answer:
If you isolate each choice to its own and selected it if it applies to the question, then youll end
up choosing options: 3, 4, 5, 6, and 7.

Heres the rationale for the question:

When caring for a client receiving magnesium sulfate therapy, the nurse would monitor maternal
vital signs, especially respirations, every 30-60 minutes and notify the physician if respirations
are less than 12, because this would indicate respiratory depression. Calcium gluconate is kept on
hand in case of magnesium sulfate overdose, because calcium gluconate is the antidote for
magnesium sulfate toxicity. Deep tendon reflexes are assessed hourly. Cardiac and renal function
is monitored closely. The urine output should be maintained at 30 ml per hour because the
medication is eliminated through the kidneys.
Therapeutic communication Questions:
1. Responses that focus on the clients feelings
Most clients at some time find it difficult to express their feelings whether they have a terminal
illness, pregnant, or are scheduled for surgery. Any nursing response that elicits these feelings
would be therapeutic. Listen and attend to those client cues. For example the question below:
SITUATION: A 20 year old college student is admitted to the medical ward because of sudden
onset of paralysis of both legs. Nikki reveals that the boyfriend has been pressuring her to
engage in premarital sex. The most therapeutic response by the nurse is:
a. I can refer you to a spiritual counselor if you like.
b. You shouldnt allow anyone to pressure you into sex.
c. It sounds like this problem is related to your paralysis.
d. How do you feel about being pressured into sex by your boyfriend?
For this question, the correct answer is D. The statement focuses on the expression of feelings
and is therapeutic. Option A is not therapeutic because the nurse passes the responsibility to the

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counselor. Option B. is giving advice is not therapeutic as it virtually terminates the
conversation. Option C is not also therapeutic because if confronts the underlying cause.
When it seems as if clients would like to discuss fears, concerns, angry feelings, then encourage
their expression.
2. Responses that are honest and direct
It is important that the nurse is honest with her responses to encourage trust and build a
therapeutic relationship. Honesty will support a trustful and a firm relationship.
Situation: An old woman was brought for evaluation due to the hospital for evaluation due to
increasing forgetfulness and limitations in daily function. She says to the nurse who offers her
breakfast, Oh no, I will wait for my husband. We will eat together The therapeutic response
by the nurse is:
a. Your husband is dead. Let me serve you your breakfast.
b. Ive told you several times that he is dead. Its time to eat.
c. Youre going to have to wait a long time.
d. What made you say that your husband is alive?
The correct answer is option A. Since the client has signs of dementia, she should be reoriented
to reality and be focused on there here and now. Option B is not a helpful approach because of
the short term memory of the client. Option C indicates a pompous response. Option D is
cognitive limitation of the client makes the client incapable of giving explanation.
3. Responses that involve active listening
Encouraging clients to talk through verbal and nonverbal techniques are supportive and serves to
further the relationship.
The nurse observes a client pacing in the hall. Which statement by the nurse may help the client
recognize his anxiety?
A. I guess youre worried about something, arent you?
B. Can I get you some medication to help calm you?
C. Have you been pacing for a long time?
D. I notice that youre pacing. How are you feeling?
The answer here is D. By acknowledging the observed behavior and asking the client to express his
feelings the nurse can best assist the client to become aware of his anxiety. In option A, the nurse is
offering an interpretation that may or may not be accurate; the nurse is also asking a question that
may be answered by a yes or no response, which is not therapeutic. In option B, the nurse is
intervening before accurately assessing the problem. Option C, which also encourages a yes or
no response, avoids focusing on the clients anxiety, which is the reason for his pacing.

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4. Responses that indicate acceptance of the client
Accept the client whatever or how he is regardless of his condition and verbalizations. Additionally,
you would not want to reject the client even if you could not condone or accept his behavior.
A male client tells the nurse he was involved in a car accident while he was intoxicated. What
would be the most therapeutic response from nurse Julia?
A. Why didnt you get someone else to drive you?
B. Tell me how you feel about the accident.
C. You should know better than to drink and drive.
D. I recommend that you attend an Alcoholics Anonymous meeting.
Choosing option A would make the client feel defensive and intimidated. Option C is judgmental;
remember any judgmental approach is not therapeutic. Option D is about giving advice and here, the
nurse suggests that the client isnt capable of making decisions, thus fostering dependency. For this
question, option B is the correct answer as it encourages the widest range of client response and
makes the client be an active participant in the conversation.
5. Responses that pick up or relate to the clients cues
Responding to an important cue is essential therapeutic technique if the nurse is to focus on the client
and maintain a goal-focused interaction.
A newly admitted client diagnosed with obsessive-compulsive disorder (OCD) washes hands
continually. This behavior prevents unit activity attendance. Which nursing statement best
addresses this situation?
A. Everyone diagnosed with OCD needs to control their ritualistic behaviors.
B. It is important for you to discontinue these ritualistic behaviors.
C. Why are you asking for help if you wont participate in unit therapy?
D. Lets figure out a way for you to attend unit activities and still wash your hands.
The most appropriate statement by the nurse is, Lets figure out a way for you to attend unit
activities and still wash your hands. This statement reflects the therapeutic communication
technique of formulating a plan of action. The nurse attempts to work with the client to develop a
plan without damaging the therapeutic relationship or increasing the clients anxiety.

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