0789732696 AppB 4/26/05 2:20 PM Page 1

B
Things You Forgot
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Throughout this book, we have tried to help you to simplify preparation for
the NCLEX® exam. This appendix includes information you have learned
during nursing school but might have forgotten.

Therapeutic Drug Levels

Here are some of the therapeutic blood levels that are important for the
nurse to be aware of when taking the NCLEX® exam:
➤ Digoxin: 0.5–2.0 ng/ml

➤ Lithium: 0.6–1.5 mEq/L

➤ Dilantin: 10–20 mcg/dl

➤ Theophylline: 10–20 mcg/dl

Vital Signs
Here are some of the normal ranges for vital signs:
➤ Heart rate: 80–100 beats per minute

➤ Newborn heart rate: 100–180 beats per minute

➤ Respiratory rate: 12–20 respirations per minute

➤ Blood pressure: systolic = 110–120 mm Hg; diastolic = 60–90 mm Hg

➤ Newborn blood pressure: systolic = 65 mm Hg; diastolic = 41 mm Hg

➤ Temperature: 98.6 +/–

0789732696 AppB 4/26/05 2:20 PM Page 2

2 Appendix
. . . . . .B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Anticoagulant Therapy
These are the tests to be done for the client taking anticoagulants and their
control levels. Remember that the therapeutic range is 1.5–2 times the
control:
➤ Coumadin (sodium warfarin) PT/Protime: 12–20 seconds.

➤ International normalizing ratio (INR): 2–3.

➤ The antidote for sodium warfarin is vitamin K.

➤ Heparin and heparin derivatives partial thromboplastin time (PTT):

30–60 seconds.
➤ The antidote for heparin is protamine sulfate.

Intrapartal Normal Values

Here are some of the normal ranges to remember when caring for the client
during the intrapartal period:
➤ Fetal heart rate: 120–160 beats per minute

➤ Variability: 6–10 beats per minute

➤ Contractions:

➤ Frequency of contractions: every 2–5 minutes

➤ Duration of contractions: less than 90 seconds

➤ Intensity of contractions: less than 100 mmHg

➤ Amniotic fluid amount: 500–1200 ml

Standard Precautions
Standard precautions are a set of guidelines for the nurse to take when car-
ing for the client. These precautions protect the nurse from transmitting the
disease to another client or to herself:
➤ Gloves should be worn when there is a chance of contact with blood and
body fluids, when handling other potentially infected material, and when
performing vascular access procedures.
0789732696 AppB 4/26/05 2:20 PM Page 3

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Things
. . . . You
. . .Forgot
3
. . .

➤ Gloves should be changed after each client contact and between contact
procedures with the same client.
➤ Masks and protective eyewear should be worn when there is a likelihood
of splashes or when body fluids might become airborne.
➤ Gloves and aprons should be worn during procedures in which there is
the likelihood of splashes of blood or body fluids.
➤ Hand washing should be done immediately after contact with body flu-
ids or other potentially infected material and as soon as gloves are
removed.
➤ Needles and sharps should be disposed of in sharps containers. No
recapping, bending, or breaking of needles should occur.
➤ Mouth-to-mouth resuscitation should be performed using a mouthpiece
or other ventilation device.

Body fluids likely to transmit blood-borne disease include blood, semen, vaginal/
cervical secretions, tissues, cerebral spinal fluid, amniotic fluid, synovial fluid, pleural
fluid, peritoneal fluid, and breast milk. Body fluids not likely to transmit blood-borne
disease unless blood is visible include feces, nasal secretions, sputum, vomitus,
sweat, tears, urine, and saliva (the exception is during oral surgery or dentistry).

Airborne Precautions
Examples of infections caused by organisms suspended in the air for pro-
longed periods of time are tuberculosis, measles (rubella), and chickenpox.
Place these clients in a private room. Healthcare workers should wear a
HEPA mask or N-95 mask when dealing with such clients. These mask con-
tain fine fibers and filter out particles, preventing them from passing through
to the healthcare worker.

Droplet Precautions
Infections caused by organisms suspended in droplets that can travel 3 feet,
but are not suspended in the air for long periods of time are influenza,
mumps, pertussis, rubella (German measles), diphtheria, pneumonia, scarlet
fever, streptococcal pharyngitis, and meningitis. Place the client in a private
room or in a room with a client who has the same illness. The clients should
be no closer than 3 feet away from one another. Caregivers should wear a
mask, and the door can remain open.
0789732696 AppB 4/26/05 2:20 PM Page 4

4 Appendix
. . . . . .B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Contact Precautions
Infections caused by organisms spread by direct contact include RSV, scabies,
colonization with MRSA, and VRE. Place the client in a private room or
with a client with the same condition. Caregivers should wear gloves when
entering the room and wear gowns to prevent contact with the client. Hands
should be washed with an antimicrobial soap before leaving the client’s room.
Equipment used by the client should remain in the room and should be dis-
infected before being used by anyone else. The client should be transported
only for essential procedures; during transport, precautions should be taken
to prevent disease transmission.

Chemoprophylaxis After Occupational

Exposure to HIV
Should the nurse be exposed to HIV, several interventions should be taken
immediately. These interventions involve the use of several antiviral medica-
tions (see Table B.1).

Table B.1 Interventions in the Event of HIV Exposure

Types of Exposure Material Source Antiviral Drug
Percutaneous Blood presents a high or increased Zidovudine (ZDV);
risk for contamination (large volume Lamivudine (3TC);
blood and blood with a high titer Indinivir (IDV)
of HIV and stages of AIDS present
extreme risk of contamination).
Mucous membrane Fluid containing visible blood, other Zidovudine (ZDC);
potentially infectious fluids, tissue, Lamivudine (3TC);
and urine present a high risk of Indinivir (IDV);
contamination. Zidovudine (ZDV); DTC
Skin Fluid containing visible Zidovudine (ZDV);
blood or other Lamivudine (3TC);
potentially infectious Indinivir (IDV); Same
fluids or tissue as above
present a high risk of
contamination.
Adapted from the USPHS Guidelines Exposure to HIV 2001.
0789732696 AppB 4/26/05 2:20 PM Page 5

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Things
. . . . You
. . .Forgot
5
. . .

Revised Life Support Guidelines

(American Heart Association)
Frequently the American Heart Association releases guidelines for the care
of the client experiencing dysrrhythmias. In this section, we discuss these
guidelines and the correct method of performing cardiopulmonary resusci-
tation.

Basic Life Support—Adult

Basic life support can save the life of a client experiencing a life-threatening
arrhythmia. These guidelines include
➤ Rescue breathing and bag-mask ventilation—Deliver mouth-to-
mouth ventilations slowly over 2 full seconds with the least volume
needed to make the chest rise.
➤ Bag-mask devices—If using a bag-mask device with oxygen supplement
of at least 40%, deliver smaller tidal volume (6–7 ml/kg) over 1–2 sec-
onds. Measure effectiveness by assessing chest expansion and oxygen sat-
urations.
➤ Pulse checks—In addition to standard pulse checks, professional res-
cuers should assess for signs of circulation, including evidence of normal
breathing or any movement in response to the two rescue breaths given.
➤ Adult CPR—If there’s just one rescuer, perform chest compressions at a
rate of 100/minute (the same rate for children). Because there is an
interruption for ventilations, you won’t actually give 100 compres-
sions/minute.
➤ Chest compressions—During CPR, the rescuer should perform two
compressions to one ventilation. He should pause 2 seconds for each
ventilation. After the airway is secured, he should switch to a ratio of
five compressions to one ventilation.
➤ Chest-compression-only CPR—This is recommend if the rescuer is
unable or unwilling to perform rescue breathing.
➤ In-hospital defibrillation—AHA recommends that all healthcare
providers who might need to perform CPR should receive equipment,
education, and authorization to perform defibrillation (AHA defines
early defibrillation in a hospital or ambulatory healthcare facility as a
shock-collapse interval of less 3 minutes).
0789732696 AppB 4/26/05 2:20 PM Page 6

6 Appendix
. . . . . .B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Basic Life Support—Infants and Children

Basic life support is somewhat different for infants and children from that of
adults. These differences include
➤ Phone fast versus phone first—Perform CPR for 1 minute before
activating emergency medical services (EMS), except when the child is at
high risk for cardiac arrhythmias and is in cardiac arrest. In that case,
the rescuer should phone first to get a defibrillator on the way.
➤ Pulse check—For infants under 1 year of age, use brachial artery. For
children, check the carotid artery. Assess for other signs of circulation,
including normal breathing, coughing, and movement.
➤ Rescuer breathing/bag-mask—During infant rescue breathing, the
rescuer should cover both the infant’s nose and mouth with his own
mouth.
➤ Chest compressions—AHA now recommends the two thumb encir-
cling hands technique instead of the two finger technique previously
used.

If only one rescuer is present, two fingers should be used to provide chest com-
pressions while the other hand is used to support the infant’s head.

Treatment of Acute Coronary

Syndromes—AHA and ACLS
Guidelines
Frequently there are changes in the protocol for treatment of clients experi-
encing acute coronary syndromes. Changes in this treatment include
➤ A 12 lead ECG is useful in making a diagnosis of a myocardial infarc-
tion.
➤ Aspirin (100–325 mg) should be taken as soon as the symptoms begin.
Do not take the enteric-coated form.
➤ Prefibrinolytic therapy is recommended if transport to the hospital is
prolonged or if more than 1 hour has passed between the onset of chest
pain and the notification of an ACLS provider. For clients who are
0789732696 AppB 4/26/05 2:20 PM Page 7

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Things
. . . . You
. . .Forgot
7
. . .

candidates for recombinant tissue plasminogen activator (rtPA), AHA

does not recommend giving rtPA 3 hours after the onset of symptoms.

Drug Changes Currently in Use

These current drugs are being used to treat ventricular fibrillation and ven-
tricular tachycardia. If the client is found to be in ventricular fibrillation, the
immediate priority is to defibrillate, followed by CPR. An airway is inserted
to facilitate proper ventilation, and an IV with a large-gauge needle is begun
to provide IV medications and treat shock. Here are some things to remem-
ber about drugs used to treat ventricular fibrillation and ventricular
tachycardia:
➤ Only one antiarrhythmic per client except for rare cases—New evi-
dence suggests that lidocaine and epinephrine might not be as reliable as
previously thought and might actually worsen the client’s condition.
➤ Lidocaine—This can suppress ventricular tachycardia associated with
acute myocardial ischemia and infarction after they occur, but prophy-
lactic use is contraindicated.
➤ Amiodarone—This has been shown to outperform other antiarrhyth-
mic drugs, and AHA recommends it as a first-line antiarrythmic for
shock refractory VT/VF. Amiodarone is recommended over lidocaine
and adenosine as the initial treatment for wide complex tachycardia in
hemodynamically stable clients.
➤ Procainamide—This is recommended before lidocaine and adenosine.

➤ Aminodarone and sotalol—These are recommended for the treatment

of stable monomorphic and polymorphic VT.
➤ Epinephrine—A high dose (0.1 mg/kg) is no longer recommended for
treating cardiac arrest. Clients who received high doses of epinephrine
for cardiac arrest and survive have more complications after resuscitation
than those who receive standard doses.
➤ Vasopressin (arginine vasopressin)—This adrenergic alternative to
epinephrine is used for promoting the return of spontaneous circulation
after cardiac arrest.
➤ Magnesium—This is recommended only for the treatment of hypo-
magnesemia and torsades de pointes.
0789732696 AppB 4/26/05 2:20 PM Page 8

8 Appendix
. . . . . .B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

➤ Bretylium—This is no longer recommended for VT/pulseless or ven-

tricular fibrillation. AHA has removed bretylium from ACLS treatment
algorithms and guidelines because of the high incidence of adverse reac-
tions and the availability of safer drugs.

Defense Mechanisms Often Used by

Clients during Stressful Situations
Chapter 15, “Caring for the Client with Psychiatric Disorders,” discussed
the client with psychosis and neurosis. We also examined defense mecha-
nisms used by the client to help him cope with stressors. Here is a quick ref-
erence to some of these defense mechanisms:
➤ Compensation—The development of attributes that take the place of
more desirable ones
➤ Conversion reaction—The development of physical symptoms in
response to emotional distress
➤ Denial—The failure to regard an event or feeling

➤ Displacement—The transference of emotions to another other than the

intended
➤ Projection—The transferring of unacceptable feelings to another
person
➤ Rationalization—The dismissal of one’s responsibility by placing fault
on another
➤ Reaction formation—The expression of feelings opposite to one’s true
feelings
➤ Regression—The returning to a previous state of development in which
one felt secure
➤ Repression—The unconscious forgetting of unpleasant memories

➤ Sublimation—The channeling of unacceptable behaviors into behaviors

that are socially acceptable
➤ Suppression—The conscious forgetting of an undesirable memory
0789732696 AppB 4/26/05 2:20 PM Page 9

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Things
. . . . You
. . .Forgot
9
. . .

Nutrition Notes
It is important for the nurse to be aware of different diets used in the disease
processes we have discussed. Table B.2 is a quick reference to help you
remember the diets.

Table B.2 Dietary and Nutrition Notes to Remember

Diseases Being
Treated Foods to Include Foods to Avoid
Bone marrow Cook or peel and Avoid foods from salad bars,
transplant clients wash all foods. foods grown on or in the ground,
and foods that are cultured.
Celiac/gluten- Milk, buttermilk, lean Malted milk, fat meats, luncheon
induced diarrhea meats, eggs, cheese, meats, wheat, salmon, prunes,
fish, creamy peanut plums, rye, oats, barley, and
butter, cooked or canned soups thickened with gluten
juice, corn, bread containing grains.
stuffing from corn,
cornstarch, rice,
soybeans, potatoes,
bouillon, and broth.
Congestive heart Meats low in cholesterol Foods high in salts, canned
failure, and fats, breads, products, frozen meats, cheeses,
hypertension starches, fruits, sweets, eggs, organ meats, fried foods,
vegetables, dairy and alcohol.
products.
Crohn’s/ulcerative Meats, breads, and Whole grains, legumes, nuts,
colitis starches, fruits, vegetables with skins, prune
vegetables, dairy juice, and gristly meats
products
Full liquid diets Milk, ice cream, soups, All solid foods.
for clients who puddings, custards,
require a decrease plain yogurt, strained
in gastric meats, strained fruits
motility and vegetables, fruit
and vegetable juices,
cereal gruel, butter,
margarine, and any
component or
combination of clear
liquids.

(continued)
0789732696 AppB 4/26/05 2:20 PM Page 10

10 Appendix
. . . . . .B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Table B.2 Dietary and Nutrition Notes to Remember (continued)

Diseases Being
Treated Foods to Include Foods to Avoid
Lacto-vegetarian Primary sources of All meat products.
protein, dairy
products, peanut
butter, legumes,
soy analogs.
Peptic ulcer/hiatal Meats, breads, Alcohol, coffee, chocolate, black
hernia starches, fruits, or red pepper, chili powder,
vegetables, and carminatives such as oil of
dairy products. peppermint and spearmint,
garlic, onions, and cinnamon.
Radium implant Same as for Crohn’s Same as for Crohn’s and
clients and ulcerative colitis. ulcerative colitis.
Renal transplant Meats, dairy products, Eggs, organ meats, fried or fatty
clients breads and starches, food, foods containing salt, dried
vegetables, and sweets. foods, salt substitutes, and fruits.

Immunization Schedule
It is important for the nurse to be aware of the recommended immunization
schedule for various age groups. Figure B.1 is a recommended schedule.

Recommended Childhood and Adolescent Immunization Schedule UNITED STATES • 2005

Age 1 2 4 6 12 15 18 24 4–6 11–12 13–18
Birth month months months months months months months month years years years

HepB #1
HepB #3 HepB Series
HepB #2

DTaP DTaP DTaP DTaP DTaP Td Td

Hib Hib Hib Hib

IPV IPV IPV IPV

MMR #1 MMR #2 MMR #2

Varicella Varicella

PCV PCV PCV PCV PCV PPV

Influenza (Yearly) Influenza (Yearly)

Vaccines below dotted line are for selected populations

Hepatitis A Series

Figure B.1 Recommended immunization schedule.