NCLEX priority

  1. Stable (8)
    • Use of word stable
    • Chronic
    • Post op more than 12 hours
    • Local/regional anesthesia
    • Lab abnormalities A/B
    • Ready/ to be discharged, admitted longer than 24 hours ago
    • unchanged assessment
    • expected s/sx
  2. Unstable (8)
    • Use of word unstable
    • acute
    • post up less than 12 hours
    • general anesthesia
    • Lab abnormalities C/D
    • newly admitted/diagnosed, admitted less than 24hr ago
    • changed assessment
    • unexpected s/sx
  3. always unstable (4)
    • hemorrhage
    • hypoglycemia
    • fever over 104
    • pulselessness/breathlessness
  4. tie breaker- vital organs
    • Brain
    • Lung
    • Heart
    • Liver
    • Kidney
    • Pancreas
    • Black Lipstick Has Left Kisses Passionately
  5. NO LPN
    IV, unstable pt, admin, discharge, first, blood transfusion, plan of care
  6. NO UAP
    meds, assessments, treatments, firsts
  7. Is staff doing something illegal ?
    tell supervisor
  8. Is pt or staff in harms way ?
    intervene immediately
  9. Is it just inappropriate ?
    council later on
  10. K (D)(C)
    • 6 or above
    • Hold K, assess heart, prepare D5W insulin/kayexelate, Call MD
    • C: 5s
    • TL: 3.5-5
  11. PH (D)
    • 6
    • Get vitals, Call MD
  12. CO2 (D)(C)
    • 60s
    • assess resp, do pursed lip breathing, prepare to intubate, Call RT/MD
    • C: 50s
    • TL: 35-45
  13. P02 (D)(C)
    • 60 or under
    • Assess resp, give O2, prepare to intubate, Call RT/MD
    • C: 70-77
    • TL: 78-100
  14. Platelets (D)(C)
    • under 40K
    • Assess for bleeding, prepare platelet transfusion, Call MD
    • C: under 90K
    • TL: 150K-400K
  15. INR (C)
    • 4
    • Hold warfarin, assess for bleeding, prepare vit K, call MD
  16. Hemoglobin (C)(B)
    • under 8
    • assess for bleeding, prepare for transfusion, call MD
    • B: 8-11
    • TL: 12-18
  17. SAO2 (C)
    • under 93
    • assess resp, give 02
    • TL: 93-100
  18. Neutropenic (WBC, ANC, CD4)
    • WBC: Under 5K (5K-11K)
    • ANC: Under 500
    • CD4: under 200
  19. Creatine
    • 0.6-1.2
    • Elevated = (A)
  20. BUN
    • 8-30
    • elevated = (B) check for dehydration
  21. BNP
    • above 100
    • monitor for CHF
  22. NA
    • 135-145
    • B monitor for dehydration
    • C change in Neuro
Author
andreathors16
ID
323271
Card Set
NCLEX priority
Description
You can do this
Updated