The Pearls for

NCLEX Review
Course
The MOST important comprehensive
resource your students need to assist them in
successfully preparing for the
NCLEX examination.

BrainyNurses.com by
Educational Concepts, LLC

Contact us today for information about our

comprehensive 3-Day NCLEX Review Course.

Phone: (419) 305-3043

info@edconcepts.net
P.O. Box 55
Coldwater, OH 45828
 The Pearls for
NCLEX Review Course
Author: Cynthia Liette MS, APRN, ACNS-BC, CCRN
Educational Concepts, LLC

Welcome to The Pearls for NCLEX Review Course

The Pearls for NCLEX Review is written by a long-term educator and clinician who recognizes the
need to teach in ways that enhance the retention of information. The course is designed for both
RN and PN students with specific content areas identified. It encompasses their entire nursing
program and all the HESI and NCLEX review books and puts it into one manual of over 300 pages
and presented with over 1,200 visuals to enhance the retention of the material.

The program is loaded with pathophysiology, pharmacology, lab abnormalities, diagnostics, and
clinical correlation pieces. A review of the following is incorporated into this interactive seminar:

* Test taking hints * Professional development

* Fundamental skills * Principles of nutrition
* Mental health issues * Endocrine system
* Pulmonary system * Cardiovascular system
* Infections in acute care * Renal & urological systems
* Acid base overview & review * Musculoskeletal system
* Connective tissue disorders * Neurological system
* Gastrointestinal system * Reproductive system
* Accessory digestive organs * Maternity nursing
* Pediatrics * Pharmacologic principles of med administration
* Laboratory testing, normal and abnormal values for each system

We invite you to preview our comprehensive review course which prepares students with test tak-
ing techniques and the knowledge to pass the NCLEX exam on their first attempt.

The following pages includes excerpts from our program and highlights some of the teaching tech-
niques used including fill-in-the-blank, group work, diagrams, fact-filled tables, “bubble hints”,
pneumonics, and memory hints.

We have also included student comments from the countless programs we have conducted to help
them successfully pass their NCLEX Exam.

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 The Pearls for
NCLEX Review Course
Answering Priority Setting Questions
Prioritization is a key component of the exam. Students must know the order to assess patients when man-
aging a team and they must be able to prioritize interventions. Areas reviewed include Key words, Maslow,
ABCDs, triage, nursing process, and at risk patients. Numerous questions are then presented to enhance the
use of these concepts.

Key Words are used frequently to make the student think

“priority” and what to chose first. These may include:
* Initial * Essential
* Vital * Immediate
* Highest * Best
* Most * Priority

Maslow’s Hierarchy may be used to determine priority.

Physiologic and safety needs must be met first.

 Physiologic: Need for food, shelter, water, sleep, ox-

ygen, and sexual expression.
 Safety: Avoiding harm, having security and order,
and physical safety.
 Love and belonging: Giving and receiving affection
and companionship, identification with a group, respect of others, self esteem, and success in work.
 Self-actualization: Fulfillment of potential.

ABCD’s is frequently used to determine

assessment and intervention priorities.

 Airway

 Breathing (and oxygen)

 Circulation is assessed by checking:

___________________and Student Comment: “Excellent in-

structor. Very knowledgeable with
___________________ good tips to help remember every-
thing and great clinical examples to
 Disability is assessed by checking: _______________ reinforce knowledge.”

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 The Pearls for
NCLEX Review Course
Triage: Think of a stop light to determine which patients to see and
treat first.
 Red: Critical patient. Stop and treat them immediately.

 Yellow: Could be seriously ill. Caution in assessment. Treat them

in 30-60 minutes.

 Green: Go ahead and move to the next patient. See in a few hours.

 Black: Dead or dying.

“Treat those who are salvageable
first” in triage situations.

Nursing Process to determine what to do first and how to proceed.

 Assessment and data collection are priority unless the patient is critical
and then an intervention may be needed.

 Establish the nursing problem using Maslow.

 Plan and implement interventions using ABCD.

 Evaluate the response or outcome.

 Notify the physician when:

 There is a complication or critical development
 They are not progressing like they should be

At Risk Patients to determine priority for assessment and interventions

 Procedures or injuries to vascular organs by

determining mechanism of injury, organ location and clinical man-
ifestations demonstrated:
________________ _______________ ______________

 Determining patients who are unstable with the

identification of key clinical signs:
_______________________ _________________________

_______________________ _________________________
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 The Pearls for
NCLEX Review Course
Diverse Teaching Strategies
Various teaching strategies are used throughout the program to enhance student involvement and com-
prehension to keep them engaged. All conditions and disorders are reviewed using a pathophysiologic
approach with more than 1,200 visuals to assist in understanding the disease process. Bullet points and
concise definitions allow for quick review and better retention of material covered.

Chronic Renal Failure: A chronic and progressive condition where renal function is lost. Those
with end stage renal failure require dialysis to live. Renal failure is a GFR 15% to 29%. End-stage is GFR
< 15%.

Uremia or azotemia: High BUN and creatinine levels from protein metabolism. Will be seen in end stage
renal failure. Must restrict protein in these patients. GFR is the most reliable indicator of the level of protein
consumption.
Lab abnormalities Quiz Time!
What do you remember about
_____K+ _____pH and HCO3 labs and renal failure?
Work with a partner to come
_____Phosphorus _____Sodium up with the answers.

_____Magnesium _____Blood sugar

_____Calcium _____Albumin levels

_____RBC _____Protein in urine

_____PT, PTT _____Uric acid

Clinical manifestations of renal failure are related to four pathological processes:

 Anemia
 Accumulation of waste products Think about these pathological processes and
how they will manifest in your patients.
 Fluid retention
Then review the complete table included for you.
 Suppression of the immune system

Student Comment:
“The practice questions helped to identify tips to rule out
answers. Very helpful acronyms and pneumonics.”

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 The Pearls for
NCLEX Review Course
Clinical Manifestations of Chronic Renal Failure:
Skin changes Gastrointestinal
 Gray-bronze or yellow skin  Metallic or ammonia taste and breath odor
 Pallor related to anemia  Stomatitis
 Uremic frost  Increase dental caries
 Pruritis  Anorexia
 Excoriations  Increased gastric acid
 Ecchymosis and purpura  Diarrhea or constipation
 Thin, brittle nails  May develop hepatitis

Cardiovascular Central nervous system

 Hypertension  Memory problems
 Acceleration of ASHD  Mental clouding which may progress to
 Increased risk of AMI and CVA confusion
 Heart failure  Flat affect
 Pericarditis  Depression
 Pericardial effusion  Irritability
 Cardiac dysrhythmias  Stupor and coma
 Seizures
Respiratory
 Thick sputum, depressed cough Peripheral nervous system
 Uremic breath odor  Neuropathies
 Kussmaul’s respirations  Loss of motor function
 Pleural effusions  Foot drop
 Increased risk of pneumonia  “Burning feet” syndrome

Reproductive Autonomic nervous system

 Impotence in men  Poor blood pressure control
 Decreased libido  Orthostatic hypotension
 Amenorrhea
 Infertility in women Musculoskeletal
 Impaired mobility
Hematologic  Loss of muscle mass
 Anemia  Osteomalacia
 Platelet dysfunction  Osteoporosis
 Suppressed immune system

Student Comment:
“The course is straight to the point and everything I
needed to review is in one resource book.”

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 The Pearls for
NCLEX Review Course
Bullet Points & Bubble Hints
Bullet points are used throughout to give students a quick and easy way to remember clinical manifesta-
tions and treatments. Bubble hints are used to provide fun ways to remember facts.

Post-Operative Complications:
Work together with a partner and identify which conditions in the box are early and late complications.

Early complications: Late complications Possible Complications

Hypoxia
________________________ ________________________
Pulmonary embolus
________________________ ________________________ Atelectasis
Pneumonia
________________________ ________________________ Hypovolemic shock
Problems with the wound
________________________
Ileus
Atelectasis is complete or partial
collapse of the lung. Normal perfusion
but decreased ventilation. Stasis of secretions leads to bacterial growth
and pneumonia.

* Develops 24-48 hours postoperatively

Clinical Manifestations Interventions

 Dyspnea  Cough & deep breathe &
 Tachypnea incentive spirometry
 Tachycardia  Suction if necessary
 Fever  Medicate for pain
 Decreased breath sounds  Ambulate and frequent position
 Asymmetrical chest movement changes
 Increased restlessness  Bronchodilators

Student Comment:
“Fantastic class! It moved along quickly with the material which is well detailed
in the book. Loved the fill-in-the-blank areas to keep our attention and sponta-
neous group activities to change the pace of the class.”

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 The Pearls for
NCLEX Review Course

Pneumonia Deep Vein Thrombosis

Clinical Manifestations Clinical Manifestations
Tachypnea Unilateral swelling
Shallow respirations Pain in the leg
Crackles Possible redness
Productive cough
Hypoxia
Asymmetrical chest movement
Fever
Leukocytosis
Tachycardia

Pulmonary Embolism
Hypovolemic Shock Clinical Manifestations
Tachypnea
Clinical Manifestations Tachycardia
Tachypnea Increased anxiety
Tachycardia Dyspnea
Weak pulse Chest pain
Cool, clammy skin Blood tinged sputum
Restless Diaphoresis
Decreased urine output Decreased orientation
Increased bleeding Hypotension
Thirst ↓ CO2 and ↑ O2 initially on ABGs
Decreased CVP
Hypotension

Student Comments:
“This was an awesome class. Very knowledgeable in-
structor who really brought everything together for me.”

“Amazing instructor! Easy to listen to and kept our (my)

attention throughout the entire time!”

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 The Pearls for
NCLEX Review Course
Problems with the Incision
Wound Dehiscence: Separation of incision.

Type of incision most likely: ______________________

Wound Evisceration: Evidence of bowel through the incision

with increased pain. Those at risk include:
 Elderly
 Diabetic Empty out with
 Obese Evisceration
 Malnourished
 Prolonged paralytic ileus

Wound Infection
 Incisions will be red due to inflammation.
 Red with purulent drainage means a local infection which is usually staph or strep.
 Elevated WBC and fever indicates a systemic infection.

“Quick-and Dirty” Methods

Students appreciate the easy ways to remember numerous facts and conditions using “Quick &
Dirty”. The hints are used for retention of information for the exam and readily transferred into the
clinical environment for easy retention and application to practice.

Vital Signs in Pediatrics: In the pediatric population, respiratory and heart rates must be measured.
Age (yr) Resp Pulse
Document the child’s behavior with vital signs such as crying, febrile, or
other distress. Use the table on the right to remember “ballpark” normals
10-16 16-20 60-90 for the age groups:
Age Resp Pulse
5-10 18-22 70-110
Quick & Dirty Normals Adult 20 Around
3-5 20-25 80-120 80

2-3 20-30 80-130 To remember the normals, think 20, 30, Child 30 Up to
40. Then remember breaths to heart rate 120
1-2 25-35 100-150 is 1:4.
Infant 40 Up to
0-1 30-60 100-160 160

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 The Pearls for
NCLEX Review Course
Acid Base Imbalances Can also use
“Quick and dirty”
Can use R-O-M-E for interpretation for interpretation:

“If the pH and Bicarbonate

are Both in the same direc-
R = Respiratory pH ↑ PCO2↓ = Respiratory Alkalosis
tion, then it is a metabolic
problem.”
O = Opposite pH↓ PCO2 ↑ = Respiratory Acidosis

M = Metabolic pH ↑ HCO3↑ = Metabolic Alkalosis

E = Equal pH↓ HCO3↓ = Metabolic Acidosis

Sample #1: Sample #2:

pH=7.38 pH=7.10
PaCO2=40 PaCO2=35
HCO3=24 HCO3=15
PaO2=62
Interpretation: O2 Sat=70%

___________________ Interpretation:

Potassium effects in _____________________

acid-base imbalances
Additional considerations:
Check the electrolytes.
Potassium will be ______

Student Comment: Immediate intervention:

“Presented a lot of easy ways to remember
points. Great layout of information and very _____________________
much to the point. I will keep this material for a
long time to go back and reference from and
study.”

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 The Pearls for
NCLEX Review Course
Extensive Lab Review
A comprehensive review of labs and “need to know” values is incorporated throughout the program.
Values are given in ‘ball park’ ranges to help the student remember the normals. Lab ‘tid-bits’ are given
to understand relationships and how they are affected in disease conditions. Lab abnormalities with
disease pathology are reinforced throughout the course.

Labs to evaluate dehydration and renal function

BUN: Normal is 10-20. Not a great indicator of renal function. Will be high in
renal dysfunction in conjunction with the creatinine.
 Used more often to evaluate dehydration. Creatinine < 1.2
 Value decreased in liver dysfunction because BUN 10-20
the liver can’t make BUN. BUN : Ct ratio 20:1
indicates renal failure
Creatinine < 1.2. Increases in renal failure.

Hemoglobin: 12-18 (a dozen to a dozen and a half)

Hematocrit (Hct): 36-54 (three times the hemoglobin)

Specific gravity of urine: Normal is 1.005-1.030. High values indicate dehy-

dration. >1.020 indicates hypovolemia and need for early intervention.

Sodium: Normal is 135-145. Increases with dehydration.

Student Comments:
Lab tid bits and rules
“Labs were thoroughly covered
Na+ and K+ exchange for one another and then reviewed throughout the
K+ and H+ exchange for one another course. I have a much better under-
Na+ and Cl- are buddies standing of them than ever before.”
Ca++ and Mg+ run together and HPO4 is “Thank you for the Lab Review
opposite in the absence of disease Card given during the course. Very
K+ runs with Ca++ and Mg+ helpful for remembering the values
and diagnostics.”

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 The Pearls for
NCLEX Review Course
Medication Administration
Techniques in the administration of medications are thoroughly reviewed to assist students in
answering these questions. General and significant side effects for various classifications are presented
along with interventions and nursing assessments.

Vastus Lateralis Deltoid

 Large muscle in  OK for nonirritating
adults. meds in adults.
 Use in kids at any  Never in kids.
time, even < 3
years.

Ventrogluteal Gluteus Medius or

 Preferred in adults Dorsogluteal
due to sciatic  Need to roll.
nerve injury with  Use in kids >6
dorsogluteal years.
 Use in kids > 3  May cause sciatic
years. nerve injury

Significant Side Effects with Drug Therapy

Neuroleptic malignant syndrome (NLMS)
 Fatal hyperpyrexia with temperature elevation to 108°
 Potential reaction to medications such as:
 Phenothiazines
 Cyclic antidepressants
 Olanzapine (Zyprexa)
 Overdose of haloperidol (Haldol)
 Treatment:
 Dantrolene (Dantrium) (Musculoskeletal relaxant)
 Bromocriptine (Parlodel) (Anti-Parkinson drug)

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 
The Pearls for
NCLEX Review Course
Drug Classifications
Each classification of medication includes action, side effects, toxic effects when appropriate, targeted drugs
and a complete list of medications for review. Drug therapy can also affect lab values in numerous ways and
these are included with each classification. In addition, nursing considerations with administration are
reviewed.

Diabetic Agents
 Most frequently used to treat high blood sugars. Lab effects:
↑ BUN and creatinine
 The drugs may prevent the body from absorbing glucose in the ↑ AST, ALT, ALP, Bilirubin
gastrointestinal tract, increase the ability of insulin to work, or
they may help to lower the blood sugar once it is elevated.

 Many drug interactions with these medications.

 Some of the oral drugs can cause gastrointestinal upset such as

abdominal bloating, nausea, cramping, and diarrhea.

 Insulin pens increase accuracy of dose and are used frequently.

 Clumping, frosting, and precipitate is a sign of damage to a vial

of insulin.

Types of insulin and times:

Short acting Intermediate Basal insulin

acting

Onset 30 minutes 90 minutes 1-2 hours

Peak 2-4 hours 4-8 hours 6 hours Quiz Time:

In general, can you take
Duration 6 hours 18 hours 24 hours oral drugs when pregnant?
___________
Lantus and
Regular insulin NPH
Detemir

 Clear insulin includes regular insulin and now Lantus and Detemir. Lantus and Detemir are never
mixed with any other type of insulin.

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 The Pearls for
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Adrenal and anti-adrenal agents
 Used to correct abnormalities of secretion of the adrenal gland.

 Systemic steroids can cause adrenal insufficiency if they are not

gradually withdrawn.
Lab effects:
 Side effects of steroids: ↓ WBC, ↑ BS, ↑ Na+, ↓ K+

Muscle weakness Abnormal fat distribution

Osteoporosis Growth retardation in children
Immunosuppression Weight gain
Polyuria Mood swings such as depression
Polydipsia Edema
Steroids tend to
 Medications: end in –sone

Betamethasone (Celestone) Hydrocortisone

Dexamethasone (Decadron) Methylprednisolone (Solu Medrol)
Cortisone (Cortone) Prednisone (Deltasone)
Fludrocortisone (Florinef)

Student Comments:

“Doingthe numerous review questions, made me think of questions in a differ-

ent way.”

“This course helped me with the process of elimination and prioritization and
taught me the find the correct answer.”

“It really helped show some test taking techniques and what words to look for.”

“Thank you! This course was packed full of knowledge and a great review of eve-
rything I have learned in my program. Going over the questions with the various
strategies was very beneficial.”

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 The Pearls for
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Toxic Effects from Drug Therapy
Bronchodilators: Open up the airways of the respiratory system to
allow for air passage into and out of the lungs. Major types include:
 Anticholingeric agents are taken around the clock for consistent
response. They are one of the most beneficial bronchodilators in COPD.

 Sympathomimetic agents stimulate the sympathetic nervous system and

cause SNS side effects

Restlessness Headache
Hypertension Nausea and vomiting
Tachycardia Pupil dilation
Shaking

 Xanthine derivatives have a narrow therapeutic window. Caffeinated

beverages are the same classification and can increase drug levels.
Quiz time: Do you remember the therapeutic blood level for patients on
xanthine derivatives?? _________

Signs of xanthine toxicity: Agitation Confusion

Tremors Vomiting
 Medications Insomnia

Sympathomimetic agents Anticholinergics

Arformoterol (Brovana) Ipratroptium (Atrovent)
Albuterol (Proventil, Ventolin, Volmax) Tiotropium (Spiriva)
Bambuterol (Bambec)
Epinephrine (Adrenalin, Primatene) Xanthine derivatives
Formoterol (Foradil) Aminophylline
Isoproterenol (Isuprel) Theophylline (Theo-dur, Slo-bid, Uniphyl)
Levalbuterol (Xopenex)
Metaproterenol (Alupent) Combination agent
Pirbuterol acetate (Maxair) Ipratropium and albuterol (Combivent)
Salmeterol (Serevent)
Terbutaline (Brethine)

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 The Pearls for
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Toxic Effects from Drug Therapy

Inotropic agents: Increases the force of contraction and perfusion to the organs. An increase in urine
output would indicate an increased perfusion to the kidneys.

 Side effect is a slow heart rate. Call for heart rate: < __________ OR > __________
 Signs of toxicity “Starry Night”
 Nausea by Van Gough
 Vomiting
 Diarrhea The theory is Van Gough was toxic
on foxglove (the precursor to digitalis)
 Bradycardia
when this picture was painted.
 Heart block
 Halos in the visual field This is what your patients see when
they are toxic on digoxin (Lanoxin).

 Hypokalemia and hypomagnesemia potentiate the effects of digoxin.

The patient’s level could be high normal in the presence of these electrolyte imbalances and toxic rhythms
and symptoms may develop.
 Excreted by the kidneys. Lab effects:
↓ K+ and ↓ Mg+→
 Dosage must be decreased in renal dysfunction. ↑ effects of digoxin
 Antidote for digoxin toxicity is digoxin immune fab (Digibind).

Student Comments

“The summary of each system that incorporates pharmacology and the key points is
very beneficial.”

“I so appreciated the extensive pharmacology review throughout the entire course.

We had several instructors in our program and a lack of consistency. This course put it
all together and with each body system which is extremely beneficial.”

“Thanks for all the helpful hints remembering drug classifications and side effects. I
will use this book well past my exam and as I practice as a nurse.”

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 The Pearls for
NCLEX Review Course
Use of Pneumonics
Pneumonics are very useful in helping students and practicing nurses remember numerous facts related to
disease process, clinical manifestations, and drug therapy.

Selective Aldosterone Blockers (SABs): To remember the SABs:

Potassium sparing diuretics that work in the distal tubule of the “Amy tried to Spy in the distal
tubule with potassium”
nephron. For testing, remember the following as being
potassium-sparing…..ALL the rest, in general, are potassium wasting.

Amiloride (Midamor) Combination medications:

Triamterene (Dyrenium) Amiloride + HCTZ (Midamor)
Spironolactone (Aldactone) Triamterene + HCTZ (Dyazide)

Side effects of spironolactone (Aldactone): Hirtuism

 Decreased libido
 Gynecomastia in males
 Hirtuism in females

Calcium Channel Blockers: Relax the blood vessels reducing blood pressure and improving blood
flow. Some also slow down the electrical conduction in the heart and can be used to control rapid atrial
dysrhythmias.

Medications: Side Effects include the 5 H’s

Very = Verapamil (Calan, Isoptin, Verelan) Hypotension

Headache
Nice = Nifedipine (Adalat, Procardia) Hot Flashes
Heart Block
Drugs = Diltiazem (Cardiazem, Dialcor, Tiazac) Hard Bowel Movement

Other calcium channel blockers:

Amlodipine (Norvasc) Clevidipine (Cleviprex)

Felodipine (Plendil) Isradipine (DynaCirc)
Nicardipine (Cardene) Nimodipine (Nimotop)
Nisoldipine (Sular)

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 The Pearls for
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Concise Review of Content
In the course of their studies, students are presented with an abundance of information to remember about the
various disease states, clinical manifestations and treatments. A concise review of all pertinent content is
presented and much appreciated by students.

The Adrenal Gland

Adrenal medulla secretes catecholamines such as epinephrine and
norepinephrine. Pheochromocytoma is the tumor which can occur in the
medulla resulting in excess secretion of these chemicals.

Adrenal cortex secretes the three “S’s”.

Na+ and K+
 S____________: Cortisol exchange for
one another
 S____________: Aldosterone

 S____________: Estrogen and testosterone

Disorders includes
 Hyperaldosteronism: Too much salt Lab effects:
↑ Na+, ↓ K+
 Addison’s Disease: Too little sugar, salt, and sex

 Cushing’s Syndrome: Too much sugar, salt, and sex

Hyperaldosteronism = Secretion of too much aldosterone.

 Also known as Conn’s disease.
 Kidneys hold onto sodium (and water) and throw out potassium.
 Diet: ___________________ ____________________
 Can be caused by an aldosteronoma which is an aldosterone-
secreting adenoma of the adrenal cortex.

The “AC” of the adrenal glands are Addison’s and Cushing’s

Addison’s: “Too little” * * * Cushing’s: “Too much”

“You have too little before you have too much”

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Addison’s Disease Lab effects in Addison’s
↓ Na+, ↑ K+, ↓ BS, ↑ Mg
 Not enough sugar, salt, and sex.
 Most commonly caused by an autoimmune process, failure to withdraw steroids, hemorrhage, and
drugs such as ketoconazole (Nizoral), phenytoin (Dilantin), and rifampin (Rifadin).
 Adrenal crisis can occur and is triggered by stress or sudden withdrawal of steroids. Lose the ability
to hold onto sodium and water, become hypovolemic and can go into shock and die with the crisis.

Clinical Manifestations:

Addison’s Disease Adrenal Crisis

 Hypoglycemia  Profound fatigue
 Postural hypotension  Dehydration
 Weight loss  Vascular collapse
 GI disturbances  Hypotension
 Diarrhea due to hyperkalemia  Renal shut down
 Weakness from hyperkalemia
 Bronze pigmentation of skin
 Changes in distribution of body hair

Treatment:
 Life-long hormone replacement therapy
 Hydrocortisone IV to reverse a crisis. Helpful Hint: Any total
 Steroid therapy such as prednisone (Deltasone) adrenalectomy questions,
 Aldosterone replacement if a sodium deficit with treat like Addison’s Disease
 Fludrocortisones (Florinef) orally
 Normal saline intravenously

Student Comments:
 “Great refresher course! Gave me easier ways to study, great hints, and areas to focus on.”
 “I liked all the pneumonics to help me remember facts.”
 “This course ‘took out all the fluff’ and gave me ‘just the facts’ so I could remember them for
my exam.”
 “One of the best lectures I have ever had. Very thorough and easy to understand. The power
point was really good in helping to understand pathophysiology and disease process. I gained
so much through this course!”

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 The Pearls for
NCLEX Review Course
Cushing’s Syndrome is too much sugar, salt, and sex, especially cortisol. Condition may be due to
overproduction of hormones or long term use of steroids.

Clinical Manifestations:
 Hyperglycemia
 ↑ risk of infection
 Fat deposits on back
 Personality changes, irritability
 Osteoporosis
 Thin extremities
 GI distress - ↑ acid
 Thin skin
 Hypertension
 Moon face
+
 Na and fluid retention
 Profound weakness due to hypokalemia
 Bruises and petechiae
 Purple striae
 Males: Gynecomastia
 Females: Amenorrhea and hirsutism

Lab effects in Cushing’s

↑ BS, ↑ Na+, ↓K+, ↓ WBC

Sample Slide from the Program

Cushing’s
Syndrome

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 The Pearls for
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Comparison Tables
Numerous conditions are contrasted such as hyper and hypothyroidism, left and right -sided heart
failure, and many others. Students are taught how to apply contrasting when answering many of

Thyroid Disorders
Hyperthyroidism Hypothyroidism
 Intolerance to heat  Intolerance to cold
 Insomnia  Lethargy
 Irritability  Apathy
 Fine, straight hair  Dry skin
 Exophthalmos  Brittle nails and hair
 Facial flushing  Receding hairline and hair loss
 Enlarged thyroid  Facial and eyelid edema
 Tachycardia  Thick tongue, slow speech
 Increased systolic BP  Blank expression
 Breast enlargement  Muscle aches and weakness
 Weight loss  Extreme fatigue
 Muscle wasting  Anorexia with weight gain
 Localized edema  Constipation
 Finger clubbing  Menstrual disturbances
 Tremors
 Diarrhea Late Clinical Manifestations
 Amenorrhea  Subnormal temperature
 Bradycardia
 ↓ LOC
 Thickened skin
 Cardiac complications

Student Comments:

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fact that we were walked through the pathophysiology so the signs and symptoms clicked and
made sense.”

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 The Pearls for
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Clinical Manifestations of Diabetes

Both Type I Type II Loose weight

 Early onset before 15 yr,  Late onset usually
and muscle
______________  Rapid onset after 40 yr
mass when
 Insulin dependent  Slow onset
______________  DKA may occur  Meds, exercise, diet blood sugar
 Weight loss  DKA not common not regulated.
______________  Fatigue  HHNK may occur
 ↑ frequency of infections  Weight gain prior to
 Bed wetting diagnosis
 Headache  Eye problems

Embolic Conditions
Lab effects:
 Emboli from various origins ↑ pH, ↓ pO2, ↓ pCO2
 Deep vein thrombosis
 Long bone or pelvic fracture
 Atria in atrial fibrillation or atrial flutter.
 Recognition of predisposition with Virchow’s triad.
 Treatment includes activity restrictions, anticoagulants, and in
some situations, thrombolytics or surgical embolectomy
 Clinical manifestations include:

Pulmonary embolus
Chest pain Fat embolus
Dyspnea Hypoxemia Embolic stroke
Hemoptysis Confusion Sudden onset
Tachycardia Fever Hemiparesis
Fever Upper chest petechiae Visual field deficits
Behavior changes

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Assessment Findings & Techniques
Important assessment techniques and findings are reinforced for each body system and important pathological
conditions. This assists the student in recognizing pathophysiology and needed interventions for the
questions they will be given.

Assessment of Lung sounds

Listen with the diaphragm of the stethoscope.

Bronchial: Heard over the trachea. If over the

periphery means consolidation and
pneumonia.

Bronchovesicular: Heard over the main

bronchi.

Vesicular: Normal breath sounds heard over the

periphery.

Crackles: Hear with heart failure.

Rhonchi or gurgles: Moist sounds that clear

with coughing. Usually indicates a need for
suctioning

Stridor: Assess by listening over the trachea.

Wheezing: Indicates air moving through narrow

air passages.

Pleural friction rub: Heard early in pleurisy.

Breath sounds stop at T-10 with end expiration

Student Comment:
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and very helpful! I learned so many additional facts and ways to remem-
ber and correlate information.”

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Assessment of Heart Tones
Aortic valve: 2nd ICS, RSB

Pulmonic valve: 2nd ICS, LSB

Tricuspid valve: 4th ICS, LSB

Order heard:
Mitral valve and PMI: 5th ICS, MCL S4-S1-S2-S3

To remember:
All (Aortic) Physicians (Pulmonic)
Take (Tricuspid) Money (Mitral)

Erb’s point: 3rd ICS, LSB.

Aortic and pulmonic murmurs

S1: Mitral and tricuspid valves close

S2: Aortic and pulmonic valves close

S3: Increased filling pressure

(Heart failure)

S4: Resistance to ventricular filling

(Acute MI)

Clinical Manifestations in Pericardial Effusion

Helpful Hint:
Signs & Symptoms Fluid and pressure
Hypotension around the heart
Jugular Vein Distention preventing right
Muffled Heart Tones atrial filling, lead-
Tachycardia ing to ↓ venous
return, and
Paradoxical Pulse
↓ cardiac output

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 The Pearls for
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Rhythm Strips & Waveforms
The cardiac cycle is presented with an understanding of the various waveforms and important
rhythm which can be tested. Important aspects of assessment and treatment of the rhythms are
included. ECG rhythm changes are also incorporated with electrolyte imbalances.

Rhythm Strip Interpretation

P wave is the first part of the beat. It signifies the atria

have contracted. If there are no P waves, the problem
is with the SA node.

The PR interval is from the beginning of the P wave

to the beginning of the QRS complex. If they talk
about heart blocks, the problem is in the AV node.
PR interval = 0.14-0.20
PR interval > 0.20 is first degree block

The QRS complex is the tallest part and signifies the

ventricles have contracted. Wide QRS complexes are
associated with hyperkalemia. Sample Slide from the Program
QRS = 0.08-0.12

The ST segment is the point where the end of the QRS and the T wave join. ST segment elevation signi-
fies ischemia over the area of the infarction.

The T wave signifies return to resting for the heart. Tall and peaked T waves can mean hyperkalemia. If
you defibrillate on the T wave, ventricular fibrillation can result.

QT interval is from the beginning of the QRS complex until the end of the T wave. It is prolonged in
bradycardia and with some medications and conditions.

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ECG Changes Reinforced with Electrolyte Imbalances

Hypokalemia

Hyperkalemia
Rhythm Strip Interpretation: Asystole
 Lack of rhythm with no QRS complexes. It may also be called cardiac standstill.
 Patients will die within 8 minutes if not corrected.
 Give epinephrine and atropine to treat the rhythm.
 May give sodium bicarbonate if prolonged.

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Rhythm Strip Interpretation: Atrial Flutter

 Saw tooth pattern of the P waves.

 Can be associated with strokes due to turbulent blood flow through the chambers and valves.
 Patients need to be on warfarin (Coumadin).
 Must use heparin when pregnant.

Rhythm Strip Interpretation: Atrial Fibrillation

 Chaotic P waves are seen. Atria quiver leading to clot formation.

 Can be associated with strokes and/or pulmonary emboli due to turbulent blood flow through the
chambers and valves.
 Patients need to be on warfarin (Coumadin).
 Must use heparin when pregnant.

Rhythm Strip Interpretation: Sinus rhythm with third degree AV block

 No relationship between P waves and QRS complexes
 Treatment for heart blocks and bradycardia includes:
◘ Atropine, dopamine, epinephrine ◘ Transcutaneous pacemaker
◘ Temporary transvenous pacemaker ◘ CPR until pacing initiated
◘ Stop offending drugs ◘ Permanent pacemaker in some

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Rhythm Strip Interpretation: Ventricular Fibrillation

 Chaotic QRS complexes. Example of how each

 Lethal rhythm. Die within 8 minutes if not corrected.
rhythm is covered.
 Need to defibrillate the patient.
 Implantable cardioverter defibrillator for recurrent episodes.
 Most common cause of death immediately after an acute myocardial infarction (AMI) is a dysrhythmia
such as ventricular fibrillation or ventricular tachycardia.

Formulas & Diagrams

Important formulas and diagrams to assist in calculations are included along with many
examples of how they are used in questions.

Math Formulas and Sample Problem Math question:

 C to F = C x 1.8 + 32 Penicillin 250 mg PO every 8 hours is prescribed for
 1 tsp = 5 mL a child with a respiratory infection. The child
 1 tbl = 15 mL weighs 45 pounds. The safe pediatric dose is 25-50
 1 oz. = 30 mL mg/kg/day. The nurse determines that
 1 cup = 8 oz. A. The dose is too low.
 2 cup = 1 pint B. The dose is too high.
 4 cup = 1 quart = 1 liter C. The dose is within the safe range.
 2.2 lb = 1 kilogram D. There is not enough information to determine
 1 inch = 2.5 cm safe dose.

IV Formula = Volume x drop factor divided by time in minutes for the infusion

Math question:
A physician prescribes heparin 25,000 units in 250 mL of normal saline to infuse at 600 units per hour.
After 6 hours of heparin therapy, the patient’s aPTT is sub therapeutic. The physician orders an in-
crease in the infusion to 800 units/hour. The nurse should set the infusion pump to deliver how many
mL per hour?

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Care of Burns: Determining surface area
 Rule of Nines (Most commonly tested)
 Lund Browder in children but more complex
 Rule of hands using the patient’s hand

 IV fluids calculated with the Parkland (Baxter) formula

 One half of the total amount of fluid should be adminis-

tered in the first 8 hours. Calculate from the time of the
burn.

Example:
75 kg male with burns over 40% of his body
75 kg x 4 ml x 40 =12,000 ml
6,000 ml in the first eight hours
750 ml per hour

 Calculation: Weight x 4 mL/kg x

% of burned area. Assessed Behaviors Criteria for Scoring Scores
Eye opening Spontaneous 4
 Not uncommon to give over 500-
1000 ml per hour during various To verbal stimulus 3
phases of burn care. To pain 2
None 1
Glasgow Coma Scale Most appropriate Oriented 5
verbal response Confused 4
Does not include pupil response
Inappropriate words 3
and vital signs.
Incoherent 2
Maximum of 15 None 1
< 7 reflects coma state Most integrated Obeys commands 6
< 5 organ donation motor response Localizes pain 5
To calculate: (Maximum of:) Withdraws from pain 4
Eye = 4 Flexion (Decorticate) 3
Verbal = 5 Extension (Cerebrate) 2
Motor = 6
None 1

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Cohorting & Isolation Precautions
A thorough review of isolation precautions is needed prior to the exam. Knowledge of cohorting is also
expected of the student. Bullet points are reviewed along with numerous hints on answering these frequent
questions.

Contact precautions: Droplet precautions:

 Gloves only unless the health care worker  Use a mask within 3 feet of the patient.
is leaning over the patient or when any
type of drainage could come in contact Primarily seen:
with the nurse’s uniform, then a gown re-  H influenzae epiglottitis, meningitis, pneumonia
quired.  Meningococcal meningitis, pneumonia, or sepsis
 Mumps and Rubella (German measles)
Primarily seen:
 Mycoplasma pneumonia and Pertussis
 Major draining abscess, decubitus,
or cellulitis  Pharyngitis, pneumonia, or scarlet fever in infants and young
children
 C difficile
 Congenital rubella Airborne precautions:
 Acute viral conjunctivitis  Negative pressure room and N-95
 Diapered or incontinent E coli or rotavirus, mask
shigella, hepatitis A  Pulmonary tuberculosis
 Neonatal herpes simplex  Rubeola (Measles)
 Mucocutaneous, disseminated or primary
 Impetigo Airborn and contact precautions:
 Pediculosis (lice)  Chickenpox (in the hospital). (Staff
 Acute RSV in infants, children and im- not immune should not care for the
munocompromised patient)
 Scabies  Herpes zoster in immunocompro-
 Major staph or group A strep infection mised patient or disseminated
 Adenovirus pneumonia
 Possibly SARS per CDC

Isolation Precautions

Student Comment
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About the Author

Cynthia M. Liette
MS, APRN, ACNS-BC, CCRN
Ms. Liette has been a nurse for more than 30 years. She has worked in a variety of clinical settings including
intensive/coronary care, emergency room, medical-surgical units, and supervision. She currently works as a
Clinical Nurse Specialist in a rural health care system. She has been an educator for practicing nurses, nursing
students, and paramedics for more than 25 years while still maintaining a clinical practice. Her numerous sem-
inars consistently receive excellent reviews from all levels of health professionals.

She holds a Master’s Degree from Wright State University in the Clinical Nurse Specialist Adult Health track
and is Board Certified as a Clinical Nurse Specialist. She is also an ACLS instructor and is certified in both
critical care and trauma nursing.

She is owner and president of Educational Concepts, LLC. She has authored a successful pharmacology series
and has taught a wide variety of subjects including Nurse Refresher and Nurse Internship programs, Critical
Care courses, 12-Lead ECG and Rhythm interpretation, IV therapy, and Lab and ABG interpretation courses.
She is also the author of The Pearls for Medical-Surgical Nursing Certification Review course.

She is a member of Sigma Theta Tau—National Nursing Honor Society, National Association of Clinical
Nurse Specialists and the American Association of Critical Care Nurses.

Contact us today for information about our

comprehensive 3-Day NCLEX Review Course.

Phone: (419) 305-3043

info@edconcepts.net BrainyNurses.com by
P.O. Box 55 Educational Concepts, LLC
Coldwater, OH 45828

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