LECTURE 1 ** DON’T MIX UP S&S and CAUSATION


- often what causes something is the opposite of the S&S


- ex. diarrhea will cause a metabolic acidosis but once 

ACID BASES
you are acidotic your bowel shuts down and you get a 

• learn how to convert lab values to words paralytic illeus
• the rule of the B’s

= if the pH and the BiCarb are both in the same 

• when you get scenarios: 

direction -> metabolic
 -> if it’s a lung scenario = respiratory

Hint: draw arrows beside each to see directions
 - then check if the client is over-ventilating 

* down = acidosis
 (alkalosis) or under-ventilating (acidosis)

* up = alkalosis
 - remember to look at the words (ex. over, under, 

- respiratory -> has no b in it; if in other directions 
 ventilating) -> “as the pH goes so goes my PT”

(or if bicarb is normal value)
 -> VENTILATING DOESN’T MEAN RESPIRATORY 

- KNOW NORMAL pH, BiCarb, CO2 
 RATE; resp. rate is irrelevant w/ acid-base, 

ventilation has to do with gas exchange not resp. 

• Hint: DON’T MEMORIZE LISTS…know principles rate (look at the SaO2 -> if your resp. rate is fast 

(they test knowledge of principles by having you but SaO2 is low you are under-ventilating)

generate lists..) - for “select all” questions
 -> ex. PCA pump - What acid-base disorder 

- ex. in general/principle what do opioids/pain 
 indicates they need to come off of it? = respiratory 

meds do? = sedate you, CNS depressors
 acidosis (resp. depression -> resp. arrest)

* ex. what does dilaudid do? don’t memorize specifics 
 —> if it’s not lung, it’s metabolic
or a list of dilaudid, know principles of opioids (such 
 • metabolic alkalosis - really only one scenario = if
as sedation, CNS depression -> lethargy, flaccidity, 
 the PT has prolonged gastric vomiting/suctioning

reflex +1, hypo-reflexia, obtunded)
 - because you are losing ACID

- boards don’t test by lists because all books/
 * ex. GI surgery w/ NG tube with suctioning for 

classes have different lists
 3 days; hyperemesis graviderum

- otherwise everything else that isn’t lung you 

• principles of S&S acid bases: as the pH goes so pick metabolic acidosis (DEFAULT)

goes my patient (except K+)
 * ex. hyperemesis graviderum w/ dehydration 

- pH up = PT up -> body system gets more 
 acute renal failure, infantile diarrhea
irritable, hyper-excitable (EXCEPT K+)

-> alkalosis - think of a body system and go 
 • remember, you only have 4 to pick from:

high: hyper-reflexive (+3, +4 [2 is normal]), 
 - respiratory alkalosis - respiratory acidosis

tachypnea, tachycardia, borborygmi, seizure
 - metabolic alkalosis - metabolic acidosis
- pH down = PT down -> body systems shut 

down (EXCEPT K+)
 • pay more attention to the modifying phrases than
-> acidosis - think of a system and go low: 
 the original noun

hypo-reflexive (+1, 0), bradycardia, lethargy, 
 - ex. person w/ OCD who is now psychotic (psychotic 

obtunded, paralytic illeus, respiratory arrest trumps OCD); hyperemesis with dehydration (pay 

• ex. which acid-base disorders need an ambu-bag at attention to dehydration)
the bedside? = acidosis (resp. arrest)
• ex. which acid-base disorders need suction at the VENTILATION
bedside? = alkalosis (seize and aspirate) • ventilators -> know alarm systems (you set it up so
• Mac Kussmaul - Kussmaul’s (compensatory that the machine doesn’t use less than or more than
respiratory mechanism) is only present in only 1 of specific amounts of pressure)

the 4 metabolic (acid-base) disorders
 a) high pressure alarm = increased resistance 

* M = metabolic AC = acidosis
 to airflow (the machine has to push too hard to 

get air into lungs)

• most common mistake with select all questions = selecting - from obstructions: 

one more than you should (stop when you select the ones i. kinks in tubing (unkink it)

you know! don’t get caught up on the “could be’s”)
ii. water condensation in tube (empty it!)

• Hint: don’t select none or all on select all that apply iii. mucous secretions in the airway (change 

questions (never only one and never all)
positions/turn, C&DB, and THEN suction)

*** suction is only PRN!!!

• Causes of Acid-Base Imbalance:
 -> priority questions = you would check 

- scenarios and what acid-base disorder would 

kinks first, suction is not first

result (what would cause an imbalance)



 b) low pressure alarm = decreased resistance 

to airflow (the machine had to work too little 

to push air into lungs)

- from disconnections:

i. main tubing (reconnect it duh!)

ii. O2 sensor tubing (which senses FiO2 at 

the airway/trach area; black coated wire 

coming from machine right along the 

tubing - reconnect!)

• ventilators -> know blood gases


- resp. alkalosis = ventilation settings might be 

set too high (OVER-VENTILATING)

- resp. acidosis = ventilation settings might be set 

too low (UNDER-VENTILATING)
• ex. weaning a PT off ventilator -> should not be
under-ventilated, they need the ventilator; if they are
over-ventilating then they can be weaned

• never pick an answer where you don’t do something

and someone else has to do something
LECTURE 2 - how do you tell the difference between manipulation 

& dependency?

ABUSE (Psych and Med-Surge) -> NEUTRAL vs. NEGATIVE (look at what they’re 

Psychological Aspect/Psycho-Dynamics being asked to do)

-> if the sig. other is being asked to do something 

• # 1 psychological problem is the same in any/all
abusive situations = DENIAL
 neutral (no harm) its dependency/co-dependency

- abusers have an infinite capacity for denial so that 
 -> if the sig. other is being asked to do something 

they can continue the behavior w/o answering for it that will harm them or is dangerous to them they 

are manipulated
• can use the alcoholism rules for any abuse

- ex. # 1 psych problem in child abuse, gambling or 
 • how do you treat manipulation?

cocaine abuse is denial - set limits and enforce them -> “NO”

• why is denial the problem? HOW CAN YOU TREAT - easier to treat than dependency/co-dependency 

SOMEONE WHO DENIES/DOESN’T RECOGNIZE because no one likes to be manipulated (no positive 

THEY HAVE A PROBLEM self-esteem issue going on)
• denial = refusal to accept the reality of a problem • ex. how many PT’s do you have w/ denial? = 1

• treat denial by CONFRONTING the problem (it’s not ex. how many PT’s do you have w/ dependency/co-

the same as aggression which attacks the person, not dependency = 2

the problem) = they DENY you CONFRONT
 ex. how many PT’s do you have w/ manipulation = 1
- pointing out to the person the difference between 

what they say and what they do
 Alcoholism

- Hint: never pick answers that attack the person
 Wernicke’s & Korsakoff’s

-> ex. bad answers have bad pronouns - “you”
 - typically separate BUT boards lumps them together

-> ex. good answers have good pronouns - “I”, “we”
 - wernicke’s = encephalopathy

-> ex. “you wrote the order wrong” vs. “I’m having 
 - korsakoff’s = psychosis (lose touch with reality)

difficulty interpreting what you want” -> tend to go together, find them in the same PT
• loss and grief -> for this denial you must SUPPORT it
 • Wernicke Korsakoff’s syndrome:

- DABDA = denial, anger, bargaining, depression, acceptance a) psychosis induced by Vit. B1 (Thiamine) deficiency

• Hint: for questions about denial, you must look to see - lose touch w/ reality, go insane because of no B1

if it is LOSS or ABUSE
 b) primary symptom -> amnesia w/ confabulation

- loss/grief = support
 - significant memory loss w/ making up stories

- abuse = confront - they believe their stories
• How do you deal w/ these PT’s?

• #2 psychological problem in abuse = DEPENDENCY, - bad way = confrontation (because they believe what 

CO-DEPENDENCY
 they are saying and can’t see reality)

- dependency = when the abuser gets significant other 
 - good way = redirection (take what the PT can’t do 

to do things for them or make decisions for them
 and channel it into something they can do)
-> the dependent = abuser
 • Characteristics of Wenicke Korsakoff’s:

- co-dependency = when the significant other derives 
 a) it’s preventable = take Vit. B1 (co-enzyme needed 

positive self-esteem from making decisions for or 
 for the metabolism of alcohol which keeps alcohol 

doing things for the abuser
 from accumulating and destroying brain cells)

-> the abuser gets a life w/o responsibilities
 * PT doesn’t have to stop drinking

-> the sig. other gets positive self-esteem (which is 
 b) it’s arrestable = can stop it from getting worse by 

why they can’t get out of the relationship) taking Vit. B1

• how do you treat it?
 * also not necessary to stop drinking

- set limits and enforce them
 c) it’s irreversible (70% of cases) -> Hint: On boards, 

-> start teaching sig. other to say NO (and they 
 answer w/ the majority (ex. if something is majority 

have to keep doing it)
 of the time fatal, you say it’s fatal even if 5% of the 

- must also work on the self-esteem of the co-dependent 
 time it’s not)
(ex. I’m a good person because I’m saying “no”) • Drugs for Alcoholism:

• manipulation = when the abuser gets the sig. other DISULFIRAM (Antabuse)

to do things for them that are not in the best interest of = aversion therapy -> want PT’s to develop a gut 

the sig. other
 hatred for alcohol

- the nature of the act is dangerous/harmful
 -> interacts w/ alcohol in the blood to make you very ill

- how is manipulation like dependency?
 -> works in theory better than in reality

-> in both the abuser is getting the other person to 
 -> onset & duration: 2 weeks (so if you want to 

do something for them
 drink again, wait 2 weeks)

 - PT teaching = avoid ALL forms of alcohol to avoid 
 • Alcohol Withdrawal Syndrome vs. Delirium Tremens

nausea, vomiting & possibly death
 - they are both different! not the same

-> including mouthwash, aftershaves/colognes/perfumes 
 a) every alcoholic goes through withdrawal 24 hrs. 

(topical stuff will make them nauseous), insect 
 after they stop drinking

repellants, any OTC that ends with “-elixer”, alcohol-
 - only a minority get delirium tremens

based hand sanitizers, uncooked (no-bake) icings 
 - timeframe -> 72 hrs. (alcohol withdrawal comes 1st)

which have vanilla extract, red wine vinaigrette
 - alcohol withdrawal syndrome ALWAYS precedes 

delirium tremens, BUT delirium tremens does not 

• Overdoses & Withdrawals:
 always follow alcohol withdrawal syndrome

- every abused drug is either an UPPER or DOWNER
 b) AWS is not life-threatening; DT’s can kill you

-> the other drugs don’t do anything
 c) PT’s w/ AWS are not a danger to self/others; PT’s 

-> #1 abused class of drug that is not an upper or 
 w/ DT’s are dangerous to self/others

downer = laxatives in the elderly
 - they are withdrawing from a downer so they will 

a) first establish if the drug is an upper or downer
 be exhibiting upper S&S

- uppers (5) = caffeine, cocaine, PCP/LSD (psychedelic 
 - DT’s are dangerous
hallucinogens), methamphetamines, adderol (ADD drug)
 Differences AWS DT
* S&S -> make you go up; euphoria, tachycardia, 
 in Care
restlessness, irritability, diarrhea, borborygmi, 
 Diet Regular diet NPO/clear liquids

hyper-reflexia, spastic, seize (need suction)
 (because of risk for seizures which
can cause risk of aspiration)
- downers = don’t memorize names -> anything that 

Room Semi-private Private near nurses station
is not an upper is a downer! if you don’t know what 
 anywhere on (dangerous & unstable)
the med is, you have a high chance that it’s a 
 the unit
downer if it’s not part of the uppers list
 Ambulation Up ad lib Restricted bed rest -> no bathroom
* S&S -> make you go down; lethargy, respiratory 
 privileges (use bedpans/urinals)
depression (& arrest)
 Restraints No restraints Restraints (because dangerous)

(because not - not soft wrist or 4 point soft 

- ex. The PT is high on cocaine. What is critical to assess?
 dangerous) because they’ll get out

-> NOT resps below 12 because they will be high
 - need to be in vest or 2-pt. locked 

leathers (opposite 1 arm & leg, 

-> maybe check reflexes
 rotate Q2hrs, lock the free 

b) are they talking about overdose or withdrawal
 limbs 1st before releasing the 

locked ones)
- overdose/intoxication = too much

They both get ANTI-HYPERTENSIVES &
- withdrawal = not enough
 TRANQUILIZERS

- ex. the PT has overdosed on an upper -> pick the 
 - because everything is up (downer withdrawal)

S&S of too much upper
 They both get MULTIVITAMIN w/ B1
- ex. the PT has overdosed on a downer -> pick the 

S&S of too much downer
 • RN’s can accept but RPN’s can’t (because PT is unstable)

- ex. the PT is withdrawing from an upper -> not 
 - on med-surge, the RN who takes them must decrease 

enough upper makes everything go down
 their workload (i.e. reduce PT load if they take a DT PT)

- ex. the PT is withdrawing from a downer -> not 
 -> Hint: on boards, the setting is always perfect 

enough downer makes everything go up (i.e. enough staff/time/resources on the unit etc.)
• upper overdose looks like = downer withdrawal
• downer overdose looks like = upper withdrawal
• In what 2 situations would resp. depression & arrest
be your highest priority:

- downer overdose

- upper withdrawal
• In what 2 situations would seizure be the biggest risk:

- upper overdose

- downer withdrawal


• Drug Abuse in the Newborn:


- always assume intoxication, NOT withdrawal at birth

- after 24 hrs -> withdrawal

- ex. caring for infant of a Quaalude addicted mom 24 

hrs. after birth, select all that apply:

-> downer withdrawal so everything is up = exaggerated 
 

startle, seizing, high pitched/shrill cry
DRUGS
 • Why draw levels? = narrow therapeutic window

AMINOGLYCOCIDES - small difference between what works and what kills

• powerful class of antibiotics (when nothing else - if the drug has a wide range then you wouldn’t 

works pull these outs, the big guns)
 need to draw TAP levels

- don’t use unless anything else works * ex. Lasix doses range from 5-80mg thus a wide 

• boards love to test these drugs because they’re range so you won’t need TAP levels

dangerous and are a test of safety * ex. Dig doses range from 0.125 - 0.25 so this 

• think: A MEAN OLD MYCIN 
 narrow range needs TAPS levels
-> a mean old = they treat serious, life-threatening, 
 • A MEAN OLD MYCINS = major class that needs
resistant, Gram-neg bacteria infections (i.e. a mean 
 TAPs drawn because of narrow window
old antibiotic for a mean old infection)
 • When do you draw TAPS? 

-> mycin = what they end with (all end w/ -mycin) 
 -> depends on the route (don’t focus on the med)

** not all -mycin’s are aminoglycosides BUT most 
 a) Trough Levels

are (the 3 that are not are erythromycin, 
 ** doesn’t matter which route or med, always 30 mins.

azithromycin, clarithromycin = throw it off the list!)
 - sublingual = 30 mins. before next dose

- IV = 30 mins. before next dose

• 2 toxic effects:
 - IM = 30 mins. before next dose

i) when you see ‘-mycin’, think mice
 - Sub-Q = 30 mins. before next dose

- mice -> ears -> otto toxic
 - PO = 30 mins. before next dose

- monitor hearing, tinnitus, vertigo/dizziness
 b) Peak Levels

ii) the human ear is shaped like a kidney so next 
 ** different but depends on the route (not the med)

effect is nephrotoxicity
 - Sublingual = 5-10 mins after drug is dissolved

- monitor creatinine (not BUN, output, daily weight)
 - IV = 15-30 mins after drugs is finished infusing

* creatinine = the best indicator of kidney/renal 
 * Hint: if you get two values that are correct (i.e. a 

function (pick 24 hr. creatinine clearance over 
 15 min. answer and a 30 min. one) pick the highest 

serum creatinine if both available) without going over so 30 mins.

• #8 (fits nicely in the kidney) reminds you about 2 - IM = 30-60 mins. after administration

things about these drugs
 - Sub-Q = SEE (see diabetes lecture -> because the 

- toxic to cranial nerve 8 = ear nerve
 only Sub-Q peaks are Insulins)

- administer Q8 - PO = forget about it, too variable so not tested
• route:

- IM or IV
• do not give PO -> they are not absorbed

- if you give an oral ‘-mycin’ it will go into gut, dissolve, 

go through and come out as expensive stool (won’t 

have any systemic effect)

- EXCEPT in 2 cases = bowel sterilizers:

* hepatic encephalopathy (hepatic coma) = to get 
 The BIG 10 Drugs to Know:
ammonia down, oral ‘-mycin’s’ will sterilize the 
 1. psych drugs
bowel by killing Gram-neg bacteria (E. coli) to help 
 2. insulins
bring down ammonia and won’t harm the 
 3. anti-coagulants
damaged liver because it doesn’t go through the 
 4. digitalis
liver (also gives diarrhea, more poop out is good)
 5. aminoglycosides
* pre-op bowel surgery = it sterilizes the gut by 
 6. steroids
killing the E. coli bacteria
 7. calcium-channel blockers
- if oral, no otto or nephro toxicity because not absorbed
 8. beta-blockers
- these are neomycin & kanamycin 
 9. pain meds
* Who can sterilize my bowels? NEO KAN 10. OB drugs

• Trough and Peak levels:


- trough = drug at lowest

- peak = drug at highest

** TAP levels - trough administer peak

-> draw trough levels first 

-> administer your drug

-> draw peak levels after drug administration
LECTURE 3 CARDIAC-ARRYTHMIAS
• Interpreting Rhythm Strips (4 that need to be known
Cardiac DRUGS by sight):

CALCIUM-CHANNEL BLOCKERS a) Normal Sinus Rhythm

Calcium-Channel Blockers are like Valium for your heart = P wave before every QRS & followed by a T 

wave for every single complex

• Valium -> calm’s you down; so CCB’s calm your heart
down (ex. if tachycardic, give CCB’s but not in shock)
 -> all P wave peaks are equally distant from each 

- to REST YOUR HEART
 other, QRS evenly spaced

- not stimulants b) V-Fib = chaotic squiggly line, no pattern

c) V-Tach = sharp peaks, has a pattern

• calcium-channel blockers are negative inotropic,
chronotropic, & dromotropic drugs
 d) A-Systole = flat-line

- fancy way of saying that they calm the heart down
POSITIVE NEGATIVE
• Terminology:

- if QRS depolarization, it’s talking about ventricular 

Inotropes Cardiac Stimulants Cardiac Depressants

- stimulate, speed 
 - calm the heart down, 
 (so rule out anything atrial)

Chronotropes up the heart weaken & slow down - if it says P-wave then it’s talking about atrial

Dromotopes
• 6 Rhythms most tested on N-CLEX:

• When do you want to “depress” the heart? What do 1. “a lack of QRS’s” = A-systole

CCB’s treat?
 - flat-line, no QRS

A: anti-hypertensives
 2. “P-wave” = Atrial

- relax heart & blood vessels to bring down BP
 - if it’s a sawtooth wave, always pick atrial flutter

AA: anti-angina’s
 3. “chaotic” - A-fib if w/ P-wave

- relax heart to use less O2 to make angina go away
 4. “chaotic” - V-fib if w/ QRS 

- treats angina by addressing oxygen demand
 - Hint: the word ‘chaos’ is used for fibrillation

AAA: anti-atrial arrhythmia
 5. “bizarre” = atrial tachycardia if w/ P-wave

- ex. atrial flutter, A-fib, premature atrial contractions
 6. “bizarre” = ventricular tachycardia if w/ QRS

- never ventricular
 - Hint: the work ‘bizarre’ is used for tachycardias
*** what about supra-ventricular tachycardia?? 
 • PVC’s (premature ventricular contractions)

-> because it means ‘above the ventricles’ (which 
 = a.k.a. periodic wide bizarre QRS

are the atria) - ventricular because QRS

• Side-Effects:
 - bizarre -> tachycardia

H & H = headache & hypotension
 - you can call a group of PVC’s a short run of V-tach

-> hypoTN - from relaxed heart & vessels
 - do Physician’s care about PT’s having PVC’s?

-> headache - vasodilation to brain
 -> NO, not a high priority = low priority

** Hint: headache is a good thing to select for 
 -> 3 circumstances when you could elevate these 

‘select all that apply’ questions (ex. low Na & high 
 PT’s to moderate priority (never reach high)

Na = headache, high & low glucose = headache, high & 
 i. if there are more than 6 PVC’s in a minute

low BP = headache) ii. if there are more than 6 PVC’s in a row

iii. if the PVC fall on the T-wave of the previous 

• Names of Calcium-Channel Blockers:
 beat (R on T phenomenon)

- anything ending in ‘-dipine’
 -> most common order if you call the MD about a 

- ex. amlodipine, nifedipine
 PT w/ PVC’s = D/C monitor (because then you 

- NOT just ‘-pine’
 can’t see the PVC’s and then you won’t call them)
- also includes: VERAPAMIL & CARDIZEM
 • Lethal Arrhythmia’s:

- which can be given as continuous IV drip??
 - HIGH PRIORITY, 2 main ones (will kill you in 8 mins 

= Cardizem or less) -> these PT’s will probably be top priorities

• What VS needs to be assessed before giving a CCB?
 a) A-Systole

- BP = because of risk of hypoTN
 b) V-Fib

-> parameters/guidelines - hold CCB if systolic is 
 ** both have in common = no cardiac output

under 100 
 -> no brain perfusion (and you’ll be dead in 8 mins)
-> so you need to monitor BP if PT is on a Cardizem 
 • V-tach = potentially life-threatening (but not actually
continuous drip (if it’s under 100 then you may 
 life-threatening), but still makes it a fairly high priority

have to stop or change the drip rate) - difference is that these PT’s have cardiac output
• in codes, even if the rhythm changes, if there is no
cardiac output it’s just as bad as the previous rhythm
• Treatment (more drugs):
 b) Basilar = at the bottom of the lungs, thus it is 

a) PVC’s b) V-tach
 removing blood/liquid (because of gravity) 

= for ventricular use LIDOCAINE/AMIODARONE
 - ex. it’s bad if your basilar tube is bubbling or not 

* in rural areas more Lidocaine use (cheaper & 
 draining any mL
longer shelf-life)
 • ex. How many chest tubes & where would you place them
c) Supra-Ventricular Arrhythmia’s
 for a unilateral pneumohemothorax?

= atrial arrhythmia’s use ABCD’s
 - 2 chest tubes (apical for pneumo, basilar for hemo)
• A -> ADENOCARD (Adenosine)
 • ex. How many chest tubes & where would you place them
- have to push in less than 8 seconds (FAST IV 
 for a bi-lateral pneumothorax?

push) -> slam this drug, followed by a flush; use a 
 - 2 tubes (apical on left, apical on right)
big vein; BUT the problem w/ slamming it fast is 
 • ex. How many chest tubes & where would place them for
the risk of PT going into A-Systole (for 30 seconds 
 post-op chest surgery?

but they will come out of it so don’t worry [unless 
 - 2 tubes (apical & basilar on the side of the surgery)

longer than 30 sec…])
 ** you are to assume that chest surgery/trauma is 

** for IV pushes: when you don’t know you go slow
 unilateral unless otherwise specified (they will 

• B -> BETA-BLOCKERS
 say bilateral)
- all end in ‘-lol’
 • Trick Question: How many chest tubes would you
- every ‘-lol’ is a BB & every BB is a ‘-lol’
 need and where would you place them for a post-op
- are negative inotropes, chronotropes, & 
 right pneumonectomy?

dromotropes like calcium-channel blockers (a.k.a. 
 - NONE! because you are removing the lung so you 

valium for your heart so they treat A, AA, AAA & 
 don’t need to re-establish any pressure (there is not 

have same side-effects)
 pleural space)!

** generally speaking, don’t make a big difference 

between Beta- & Calcium channel blockers; 
 Troubleshooting Chest Tubes:
except that CCB are better for PT’s w/ asthma 
 • What do you do if you knock over the plastic
or COPD -> Beta-B’s bronchoconstrict 
 containers that certain tubes are attached to?

• C -> CALCIUM-CHANNEL BLOCKERS
 -> set it back up & have PT take some deep breaths

- see Beta-Blockers & CCB’s earlier
 -> NOT a medical emergency! (don’t call MD)
• D -> DIGITALIS (DIGOXIN, LANOXIN)
 • What do you do if the water seal breaks (the
d) V-Fib
 actual device breaks?)

= for V-fib you D-fib (shock them!)
 -> first = CLAMP it!!! because now positive pressure 

e) A-Systole
 can get in! don’t let anything get in

= use EPINEPHRINE & ATROPINE (in this order!)
 -> 2nd = cut the tube away from the broken device 

-> 3rd = stick that open end into sterile water

-> if epinephrine doesn’t work then use atropine
-> then unclamp it because you’ve re-established the 

water seal (doesn’t need clamp if it’s under water

*** better for the tube to be under water than 

CHEST TUBES clamped! -> air can’t go in and stuff can still keep 

• purpose is to re-establish negative pressure in the coming out (if clamped, nothing can come out 

pleural space (so that the lung expands when the which is what the tube is for)
chest wall moves)
 • Ex. If they ask what the first thing is to do if the seal
- pleural space -> negative is good (negative pressure 
 breaks -> Clamp! BUT, if they ask what’s the best
makes things stick together)
 thing to do -> put end of tube under water! (because it
- ex. gun shot to the lung add positive pressure actually solves the problem, clamping is a temp. fix)
• Hint: when you get a chest tube question, look at the • Hint: ‘BEST’ vs. ‘FIRST’ questions

reason for which it was placed (will tell you what to - first questions = are about what order

expect & what not to expect)
 - best questions = what’s the one thing you would do if 

- ex. pneumothorax = to remove air (because air 
 you could only do 1 of the options

created the positive pressure)
 -> ex. You notice the PT has V-fib on the monitor. You 

- ex. hemothorax = to remove blood
 run to the room and they are non-responsive with 

- ex. pneumohemothorax = to remove blood & air
 no pulse. What is the first thing you do?

A) place a backboard?

• Hint: Also, pay attention to the location of the tubes:
 B) begin chest compressions?

a) Apical = the chest tube is way up high, thus it is 
 - “first” is about order so = pick A (because you 

removing air (because air rises)
 wouldn’t start chest compressions first)

- ex. it’s bad if you’re apical tube is draining 200 mL or 
 - BUT, if the question ask “What’s the best thing to 

it is not bubbling
 do?” -> you only get to do 1 thing not the other so 

you would pick B
• What do you do if the chest tube gets pulled out?
 CONGENITAL HEART DEFECTS
- first = take a gloved hand and cover the hole
 • every congenital heart defect is either TROUBLE or
- best = cover the hole with vaseline gauze NO TROUBLE (ALL BAD or NO BAD)

• Bubbling chest tubes: (ask yourself 2 questions)
 - either causes a lot of problems or it’s no big deal (no 

a) Where is it bubbling?
 in-between defect)
b) When is it bubbling?
 • memorize one word: TRouBLe
= the answer will depend on these 2 questions 
 Heart Defects TRouBLe (95% of No Trouble
all heart defects)
(sometimes bubbling is good, sometimes bad but 
 Surgery NEED surgery now - don’t need surgery 

depends on where & when)
 to live right away; possibly 

need it years later if it 

- ex. Intermittent bubbling in the water seal -> GOOD 
 causes a Trouble (but 

(document it, never bad!)
 we don’t expect it to)
- ex. Continuous bubbling in the water seal -> BAD 
 Growth & Dev. slow, delayed normal
(you don’t want this, means a leak in the system that 
 Life Expectancy short normal
you need to find and tape it until it stops leaking)
 Parent’s grief, stress, regular average person
Experiencing financial issues, lots issues
** in RPN scope
 of caregiving issues
- ex. Intermittent in suction control chamber -> BAD 
 Going Home apnea monitor no apnea monitor
(means suction is not high enough, turn it up on the 
 Hospital Stay at weeks 24-48 hours
Birth
wall until bubbling is continuous)

Who Follows Paediatric Paediatrician,
- ex. Continuous in suction control chamber -> GOOD 
 Your Care Cardiologist paediatric NP
(document it)
 Shunting R to L
 L to R
- Hint: both locations are opposites of each other 
 (TRouBLe)
(memorize one & deduce the others)
 Cyanosis Cyanotic -> Blue
 Acyanotic
(TRouBLe)
—> if there is a seal it should not be continuous 

(ex. a sealed bottle of pop continuously 
 • ex. You are teaching the parents about a heart defect:

bubbling means it’s leaking!) - pick all the options that cause trouble
• Hint: Boards will not give pictures of defects and ask
you what they are.

• A straight catheter is to a foley catheter as a
thoracentesis is to a chest tube.
 - not our job, we don’t diagnose

- in-&-out vs. continuous secured
 - our role is teaching parents the implications

-> so if it’s trouble = teach them things that it’s going 

- thoracentesis -> also helps re-establish neg. 

to be a lot of trouble

pressure (in-&-out chest tube)
 -> if it’s not trouble = pick the things saying it’s not 

- higher risk for infections are continuous going to be trouble
• There are 40+ congenital heart defects so just remember
Rules for Clamping Tubes: TRouBLe (don’t memorize all of them!):

• a) Never clamp a tube for more than 15 seconds 
 - Hint: all congenital heart defects that start w/ the 

without a doctors order.
 letter T are Trouble Defects

- so if you break the water seal -> you have 15 
 - we don’t care about the defect, we care about what 

seconds to get that tube under water we’re teaching the parents
• b) Use rubber-tipped doubled clamps.
 • All congenital heart defect kids (trouble or no trouble)
- the teeth of the clamp need to be covered w/ 
 will have 2 things:

rubber so that you don’t puncture the tube a) Murmur

- why? = because of the shunting of the blood 

(regardless of direction of shunt)

b) all have an Echocardiogram done (to find out 

what the defect is or why there’s a murmur)
• 4 Defects of Tetralogy of Fallout:

- VarieD PictureS Of A RancH (or Valentines Day Pick 

Someone Out A Red Heart)

1. VD = ventricular defect

2. PS = pulmonary stenosis

3. OA = overriding aorta

4. RH = right hypertrophy
• don’t have to recall these, RECOGNIZE them

- recall -> remember from nothing

- RECOGNIZE -> spot it when you see it (use the 

initials to recognize them in questions)
• ONLY DEFECT where they ask you what it is
INFECTIOUS DISEASE and TRANSMISSION BASED -> YES: mask, gloves, hand-washing, special-filter 

PRECAUTIONS (Isolations) mask ONLY for TB, PT mask for leaving room 

• Standard (but really shouldn’t be leaving), neg. air flow

• Universal ** disposable supplies & dedicated equipment is a 

• Contact
 good thing but not really as essential as in the 

- for anything enteric = can be caught from intestine
 other 2 (can let this one slide) 

-> fecal, oral
 -> TB: technically transmitted via droplet BUT put 

- C-Diff, Hep. A, Cholera, Dysentery
 on airborne
* things with bugs in diarrhea

* Hint for Hep A & B: Hep A -> think anus, Hep B -> 
 • PPE = Personal Protective Equipment

think blood (anything from the bowel starts w/ a vowel)
 - boards like to test how you put on or take off

- Staph infections
 - always take it off in alphabetical order

- RSV = respiratory syncytial virus (what babies, 1-2 
 -> ex. gloves, goggles, gown, mask

yr. old’s get that is not dangerous to adults but can 
 - putting on is reverse alphabetically for the ‘g’s’ & 

be fatal for them)
 mask comes 2nd

* transmitted by droplet BUT still put them on 
 -> gown, mask, goggles, gloves
contact precautions because little kids catch it 

from touching things that other sick kids touched

- Herpes infections (includes Shingles -> Herpes 

Zoster virus even though caused by varicella)

- What’s involved in contact precautions?

-> private room is preferred (but not required)

* or 2 RSV kids in the same room

* keep RSV kid & suspected RSV separate 

because you need positive cultures (not based 

on symptoms)

-> NO: mask, eye/face shield (unless for universal), 

special filter mask, PT mask, neg. air flow

-> YES: gloves, gown, hand-washing, special 

supplies & dedicated equipment (includes toys)

** disposable supply vs. dedicated equipment:

- thermometer cover - BP cuff that stays in room
• Droplet

- for bugs that travel 3 feet on large particles due to 

sneezing/coughing

- all meningitis

* cultured through lumbar puncture

- H Flu (haemophilus influenza B) -> commonly 

causes epiglotitis

* never stick something down throat because it will 

cause obstruction

- What’s involved in droplet precautions?

-> private room is preferred (but not required)

* on boards select private

* can also cohort based on positive cultures

-> NO: gown, eye/face shield, special filter mask, 

neg. air flow

-> YES: mask, gloves, hand-washing, PT worn 

mask (when leaving room), disposable supplies 

& dedicated equipment
• Airborne

- M-M-R; TB; varicella (chicken pox)

- What’s involved in airborne precautions?

-> private room is required

* unless co-horting

-> NO: gown (mostly for contact), eye/face shields

LECTURE 4 Cains:
• hold the cain on the strong side

CRUTCHES, CANES, WALKERS - a lot of people use it the wrong way
• major area of human function is locomotion so they test
these even though not a major emphasis in school
 Walkers:
- area to test PT teaching & risk reduction • pick it up, set it down, walk to it
Crutches: • if they must tie their belongings to the walker, tie it at
• How do you measure crutches?
 the sides, not the front

- boards doesn’t like things on the front (even tho most 

** need to know for risk reduction -> so you don’t 

people do that anyways; they don’t like wheels or tennis 

cause nerve damage

ball on the bottom either)
a) length of crutch = 2-3 finger-widths below anterior 

axillary fold to a point lateral to & slightly in front of the foot

-> many questions ask where you measure from/to (so for 

crutches, if they ask anything measuring from axilla to 

foot -> rule out, they’re wrong instructions for length)

b) hand grip = can be adjusted up & down; when properly 

placed, should be apx. 30 degrees elbow flexion
• How to teach crutch gaits (4 kinds):

** names are pretty obvious w/ a few exceptions

a) 2-point

- move a crutch and opposite foot together followed 

by other crutch & opposite foot

- moving 2 things together

b) 3-point

- moving 2 crutches & the bad leg together

- moving 3 things together

c) 4-point

- moving everything separately

- move any crutch, then opposite foot, followed by 

next crutch then other foot

- very slow but very stable

d) Swing-through

- for non-weight bearing injuries (ex. amputations)

- plant crutches and swing the injured limb through 

(never touches down)
• When do they use them?

- ask yourself “how many legs are affected?”

- even for even, odd for odd

* even point gaits when a weakness is evenly 

distributed (i.e. even # of legs messed up)

- 2-point = mild problems (bilateral)

- 4-point = severe problems (severe, bilateral 

weaknesses)

- 3-point = only odd one, when only 1 leg is affected
• Ex. Early stages of rheumatoid arthritis = 2-point

Ex. Left, above the knee amputation = swing-through

Ex. First day post-op right knee replacement, partial weight-

bearing allowed = 3-point

Ex. Advanced stages of ALS = 4-point

Ex. Left hip replacement, 2nd day post-op, non weight-bearing 

= swing-through

Ex. Bilateral total knee replacement, 1st day post-op, weight-

bearing allowed = 4-point

Ex. Bilateral total knee replacement, 3 weeks post-op = 2 point
• Going up & down stairs:

- up with the good, down with bad

- crutches move with the bad leg

DELUSIONS, HALLUCINATIONS, & ILLUSIONS (Psych)
 ex. person staring at a wall & says: “I see a bomb” -> hallucination

Neurosis Non-Psychotic vs. Psychosis ex. person looks at fire extinguisher on the wall and says: “I see a 

bomb” -> illusion (referent)
• Hint: the first thing you have to do to get a psych
Hint: On the test, they will tell you that there is
questions correct is decide: “Is my PT non-psychotic •
something there thus, you can differentiate between a
or psychotic?”

hallucination & an illusion.
= this will determine treatment, goals, prognosis, 

medication, length of stay, legalities…everything
NON-PSYCHOTIC PSYCHOTIC
How do you deal with these Psychotic Symptoms?
Definition Has insight & is Has no insight & is not • first thing you ask after determining if PT is psychotic:
reality-based
 reality-based What is their problem?

- even w/ emotional 
 - don’t think/know their sick

distress/illness, 
 - think everyone else has 
 —> what kind of psychosis do they have?

mental/behavioral 
 the problem but not them 

disorder
 (blame anyone else)

- recognize what the 
 - even if they say they’re 
 • 3 Types of Psychosis:

problem is and how 
 sick but then they say the 

it affects their life martians made them sick 
 1. Functional Psychosis

they don’t have insight
- can function in everyday life (i.e. have jobs, a 

Treatment/ - good therapeutic 
 - good therapeutic 

Techniques communication (like 
 communication does not 
 marriage, etc.)

any PT that displays 
 work because they are 
 - 4 diseases: Schizo Schizo Major Manics

good comm. skills)
 not rational

** there’s nothing 
 - need unique, specific 
 i. Schizophrenia

special that you need strategies
to do/know compared ii. Schizoaffective Disorder

to any med-surge,
paeds, or OB PT iii. Major Depression (if it’s major, test will say)

Symptoms don’t have delusions, DELUSIONS, iv. Manic (Acute)

hallucinations, or HALLUCINATION, -> so bi-polar is functional, only psychotic 

illusions ILLUSIONS

- only in psychotic PT’s
 during manic phase

- as soon as they get any 

of these they’ve crossed 
 - these PT’s have the potential to learn reality 

the line to being psychotic (because no damage)

-> may need meds or set boundaries for structure

Psychotic Symptoms: -> nurse role = teach reality (4 steps)

• a) Delusions
 a) acknowledge feeling -> “I see you’re angry; 

= false, fixed, idea or belief; no sensory component 
 “You seem upset”, “Tell me how you are feeling”, 

(all in the brain, thinking it)
 often uses the word feeling or shows a feeling

i. Paranoid Delusions -> people are out to harm me
 b) PRESENT REALITY -> “I know that those voices 

- ex. the mafia are out to get me
 are real to you but I don’t hear them” or telling 

ii. Grandiose Delusions -> you are superior or you 
 them what is real (“I’m a nurse & this is a hospital”)

are the world’s smartest/greatest person
 c) set a limit -> “That topic/behavior is off-limits”, 

- ex. thinking you are Christ, Genghis Khan
 “We are not going to talk about that right now”, 

iii. Somatic Delusions -> about a body part
 “Stop talking about that”

- ex. x-ray vision; there are worms in my body d) enforce the limit -> “I see you’re too ill to stay 

• b) Hallucinations
 reality based so our convo is over” (ending the 

= a false, fixed, sensory experience (purely sensory); 
 conversation NOT taking away a privilege [i.e. 

5 senses so 5 for (1 for each sense)
 punishment]; continuing to talk may enforce the 

i. Auditory -> hearing things that aren’t there (primarily 
 non-reality)

voices telling you to hurt yourself); most common
 *** on the test, they won’t ask these specific steps but 

ii. Visual -> seeing; 2nd most common
 instead, will ask “how should the nurse respond…”

iii. Tactile -> feeling things; 3rd most common
 *** try to pick the more positive statements (i.e. what 

iv. Gustatory -> tasting things that are not there
 they can have/do, not what they can’t); if between 

v. Olfactory -> smelling things that are not there
 2 statements go w/ the positive one

*** last 2 are relatively rare
• c) Illusions

= misinterpretation of reality; sensory experience
 • 2. Psychosis of Dementia

- psychosis because of actual damage to the brain

- difference from hallucination -> with an illusion there 

* in Functional Dementia, there is no brain damage; 

is a referent in reality

it’s just messed up chemicals

-> referent = something in reality to which a person 

- include PT’s w/ Alzeimer’s, psychosis after a stroke, 

refers when they say something (they just 

organic brain syndrome; anything w/ “senile” or 

misinterpret it)
“dementia”

• ex. PT says: “I hear demon voices” -> hallucination

ex. PT overhears nurses & MD’s laughing & talking at the nurse’s 
 - cannot learn reality

station & says: “Listen, I hear demon voices” -> illusion (there 
 -> major difference from functional (which is why 

is a referent)
 you have to determine type of psychosis)

 -> nurse role:
 • Narrowed Self Concept

a) acknowledge feeling
 = when a psychotic refuses to leave their room or 

b) REDIRECT them -> from something they can’t 
 change their clothes

do to something they can do
 - functional psychotic

** you don’t set-limits because it’s mean
 - #1 reason is because their definition of self is 

** NOT APPROPRIATE to present reality to these 
 narrowed -> defined self based on 2 things:

PT’s when they are experiencing psychotic 
 i. Where they are

symptoms (BUT don’t confuse this w/ reality 
 ii. What they are wearing

orientation)
 *** so they don’t know who they are unless they are 

-> important to remember that forgetting things (like 
 wearing those exact clothes in that exact room

where they are or what room they’re in - PT’s w/ 
 - as the nurse, don’t make them change or leave the 

dementia/Alzheimers) is NOT psychosis
 room (will cause escalating panic because they will 

** when they start having delusions, hallucinations or 
 lose their concept of self)

illusions, then they are psychotic
 * use the Functional Psychosis techniques
-> reality orientation = telling them person, place, 
 • Ideas of Reference

and time (ALWAYS APPROPRIATE w/ 
 = think everyone is talking about you

DEMENTIA) - this deals w/ memory
 - ex. see someone on the news and get upset 


 because you think they are talking about you

3. Psychotic Delirium
 - can have both paranoia & ideas of reference 

= a temporary, sudden, dramatic, episodic, 
 (paranoia if also think they are going to harm you)
secondary loss of reality; usually due to some 

chemical imbalance in the body

* different because it’s temporary and very acute

-> include PT’s that are short-term psychotic because 

of something else causing the psychosis

- ex. a drug reaction, high on uppers or withdrawing 

from downers (delirium tremens), cocaine overdose, 

post-op psychosis (withdrawing from a downer), ICU 

psychosis (sensory deprivation), UTI (or any occult 

infection), thyroid storm, adrenal crisis

- good thing is it’s temporary so focus is removing 

the underlying cause & keeping them safe

-> nurse role:

a) acknowledge feeling

b) REASSURE them: it’s temp. & they’ll be safe

** don’t present reality -> they won’t get it

** don’t redirect -> not going to work


• Personality Disorders are different:


A = antisocial

B = borderline

N = narcissistic

** very sick personality disorders

** may be good to use Functional Psychosis 

techniques because you set limits

Other Psychotic Symptoms:

• Loosening of Association

= your thoughts aren’t wrapped too tight, all over the map

a) Flight of Ideas

- coherent phrases but the phrases are not 

connected (not coherent together)

b) Word Salad

- sicker, can’t even make a coherent phrase

-> babble random words

c) Neologism

- making up imaginary words
LECTURE 5 2. N P H

- true intermediate acting insulin

DIABETES M. - onset = 6 hrs.

- peak = 8-10 hrs.

• definition = an error of glucose metabolism

- causes issues because glucose is the primary fuel 
 - duration = 12 hrs.

source and if your body can’t metabolize glucose, 
 - is cloudy (suspension) 

cells will die * the issue w/ suspensions is that it precipitates 

-> the particles fall to the bottom over time so 

• does not include diabetes insipidus = polyuria,
polydipsia leading to dehydration due to low ADH
 you CANNOT give via IV (or the PT will 

-> it’s just similar with the fluids, not the glucose part 
 overdose & the brain will die)

(similar symptoms)
 * Hint: general rule => never put anything 

- opposite syndromes of diabetes i. = SIADH cloudy in an IV bag

3. Lispro (Humalog)

• relationship between amount of urine & specific
gravity of urine:
 - fastest acting, rapid

- they are opposites/inverse
 - onset = 15 mins.

- i.e. the less urine out, the higher the specific gravity; 
 - peak = 30 mins.

the more urine out, the lower the specific gravity
 - duration = 3 hrs.

* so diabetes = has more urine & low specific 
 - you give this as they being to eat so with meals 

gravity (opposite with SIADH) (not ac) -> interrupt them while eating!

4. Lantus (Glargine)

TYPE I vs. TYPE II: - long acting

Differences TYPE 1 DM TYPE 2 DM
- peak = no essential peak because it’s so slowly 

absorbed -> thus, little to no risk for hypoglycemia

Names - Insulin dependent
 - Non-insulin dependent

- Juvenile onset
 - Adult-onset - duration = 12-24 hrs.

- Ketosis prone - Non-ketosis prone
- only insulin you can safely & routinely give at 

S&S - polyuria
 - same bedtime because it will not cause them to go 

- polydipsia

- polyphagia (increased 
 hypoglycemic during the night (YOU CANNOT 

swallowing, but in 

context of DM it also 
 ROUTINELY GIVE THE OTHERS AT BEDTIME)

relates to eating)
** Hint: boards likes to test peaks & tend to test it by 

Treatment D = diet —> least 
 D = diet —> MOST 

important (less 
 IMPORTANT
 giving you a time when insulin was given & asking 

restrictions than before) O = oral hypoglycemic 
 when they reach hypoglycemia (which is the peak).
I = insulin —> MOST 
 (pills) 

IMPORTANT
 A = activity • CHECK EXPIRY DATES ON INSULIN!!!

E = exercise
- What action by the nurse invalidates the 

Diet: manufacturer’s expiration date? = opening it

• primarily Type II -> the minute you open it the date is irrelevant 

• a) It is a calorie restriction.
 because now you have 30 days from opening 

- tells you that calorie’s are important because the 
 (have to write the date of opening & new expiry) 

diet’s are named (ex. 1500 calorie…)
 - refrigeration is optional in the hospital BUT you 

*** this is the best strategy for them need to teach PT’s to refrigerate at home

• b) They need 6 small feedings a day. 
 -> though at the hospital the ones that should be 

- keeps blood sugar levels more normoglycemic 
 refrigerated should be the un-opened vials 

throughout the day instead of 3 big peaks - better to give warm, non-expired insulin than cold, 


 expired insulin

Insulin:
• lowers blood glucose Exercise:
• 4 main types you really need to know:
 • exercise potentiates insulin

1. Regular Insulins -> the “R” is important
 = meaning, it does the same thing as insulin

- ex. Humulin R, Novalin R
 —> think of exercise as another shot of insulin

- onset = 1 hr.
 - if you have more exercise during the day, you need 

- peak = 2 hrs.
 less insulin shots (and bring easily metabolized 

- duration = 4 hrs.
 carbs/snacks to sports games)
- is clear (solution) so it can be IV dripped (this is 

the one used if using IV’s)

- short, rapid acting insulin (but Hesi will call it 

intermediate because we now have Lispro which 

acts faster)

Sick Days: - PT contracts upper resp. infection -> recovers 

• when a diabetic is sick -> GLUCOSE GOES UP
 w/in 3-5 days like everyone BUT after initial 

- need to take their insulin even if they’re not eating recovery, they start going downhill & getting 

• need to take sips of water because diabetics get more lethargic

dehydrated * so, if they come into the ER you should ask 

• any sick diabetic is going to have the 2 problems if they’ve had a viral upper resp. infection in 

of hyperglycemia & dehydration -> ALWAYS! the last 2 weeks

• stay as active as possible because it helps lower -> what causes the high glucose is the stress of the 

glucose (even if they’re not eating when sick) illness that was not “shut off” and they start 

burning fats for fuel -> ketosis

Complications of Diabetes:
 - S & S:

= 3 acute and a boatload of chronics
 -> spell out D K A

ACUTE - D = dehydration

• 1. Low Blood Glucose (in both types)
 - K = ketones (in blood), kussmaul’s, high K+ 

- a.k.a. insulin shock, insulin reaction, hypoglycemia, 
 * you can have ketones in your urine & not 

hypoglycemic shock
 have DKA

- What causes this?
 - A = acidotic (metabolic), acetone breath, 

-> not enough food
 anorexia (due to nausea)

-> too much insulin/medication (primary cause)
 -> hot & flushed, dry = water is a coolant! if you 

-> too much exercise
 lose water (as in dehydrate) you loose coolant

- the danger is brain damage which becomes 
 - Treatment:

permanent (so be careful not overmedicate!)
 -> fast rate IV fluids (ex. 200/hr.), w/ reg. insulin in 

- S & S:
 the bag 

-> drunk in shock

= think of how people look while drunk -> slurring, 
 • 3. High Blood Glucose in TYPE II = HHNK/HHS 

staggering, impaired judgement, delayed 
 (Hyperglycemic Hyperosmolar Non-Ketotic 

reaction time, labile (emotions all over) 
 Syndrome)

** from cerebrocortical compromise
 = this is dehydration (for any HHNK/HHS question 

= shock -> low BP, tachycardia, tachypnea, cold/
 just call it DEHYDRATION)

pale/clammy skin, mottled extremities
 - so think of the S&S of dehydration (low water, hot 

** from vasomotor compromise
 temp, flushed, dry)

- Treatment:
 - nursing diagnosis = fluid volume deficit

a) Administer rapidly metabolizable carbohydrate 
 - #1 intervention -> giving fluids!

(i.e. sugars)
 - outcomes you want to see = increased output, BP 

-> ex. any juice, reg. pop, chewable candy, milk, 
 coming up, moist mucus membranes etc.

honey, icing, jam
 ** so all the outcomes of a PT coming out of 

b) BUT combine/follow w/ a starch or protein
 dehydration

-> ex. cracker, slice of turkey
 - Why do these PT’s only get the D (& not the K & A)?

*** skim milk is great because it gives both
 -> they don’t burn fats (which make the ketones)

- bad combo is too much simple sugars (like pop & candy)

- if unconscious give Glucagon (IM) or IV Dextrose 
 • Which one is insulin the most essential in treating?

(D10, D50) -> how do you determine which to give?
 = DKA

= the setting (i.e. family calling from home, tell 
 -> you don’t have to use insulin w/ HHNK because 

them to give IM but if in ER give IV)
 you mostly need to re-hydrate them
** hard to get a vein because of vasoconstriction
 • Which has a higher mortality rate?

= HHNK

• 2. High Blood Glucose in TYPE I = Diabetic Coma/
 -> DKA’s tend to be a higher priority and symptoms 

DKA (Diabetic Keto-acidosis)
 are much more acute; HHNK’s tend to come in to 

-> Hint: Type I is also called “ketosis-prone”
 ER later than they should because symptoms are 

- What causes this?
 not as visible & they end up getting worse (so by 

-> too much food
 the time they come in it might be too far gone)
-> not enough medication
 • Who would die first if didn’t treat them? (more life-
-> not enough exercise
 threatening)

*** none of these are the #1 cause because it is 
 = DKA

acute viral upper respiratory infections (w/in the 
 -> but they tend to get treated in time
last 2 weeks)

Long-term Complications:
• related to 2 problems:

a) poor tissue perfusion

b) peripheral neuropathy
• ex. Diabetics have renal failure. What would this be due to? 

-> poor tissue perfusion

ex. Diabetic PT has lost control of their bladder and are now 

incontinent. -> peripheral neuropathy

ex. PT can’t feel it when he injures himself. -> peripheral 

neuropathy.

ex. PT doesn’t heal well when he injures himself. -> poor 

tissue perfusion

Which lab test is the best indicator of long-term

blood glucose control?
• the hemoglobin A1C (HA1C), the glycosated/
glycosylated hemoglobin (all the same)
• numbers:

- 6 & lower is what you want to see

- 8 & above means you’re out of control

** what about 7? = border

-> so they need to work done, evaluation, may 

have to go to hospital, may have an infection 

somewhere
• Hint: Boards doesn’t test units so just remember the
numbers!


LECTURE 6 5. BILIRUBIN
• waste product from the breakdown of RBC’s
DRUG TOXICITY • Hint: Boards will only test bili’s in newborns

- normal adult bili = 1-2 (low)

• 5 main ones to know

-> tests nurse safety
 - newborns have higher levels from breaking down 

-> remember, they don’t test units RBC’s from mom = 5 +
• therapeutic level -> elevated level = 10 - 20

1. LITHIUM - ex. if newborn has 9.9 it’s high but still “normal”
• bilirubin toxicity = > 20

• for the mania in bi-polar
- right around 14-15 is when MD’s start thinking about 

• therapeutic level = 0.6 - 1.2
hospitalization because once you’re at 15, you’re 

• toxic level = > 2
halfway to toxic (don’t want it to get to 18 or 19, too 

• What about between 1.2 - 2???

-> no books agree on what is going on in between 
 close to toxic)
those levels (grey area)
 • pathologic jaundice = bili high & infant yellow at birth

-> boards would not give you any values in the grey 
 - come out yellow
area (because item writers for the NCLEX need to 
 • physiologic jaundice = bili is normal at birth but over
test on what the books agree and books agree that 
 the next 2-3 days it goes high 

over 2 is toxic) - becomes yellow

2. DIGOXIN (LANOXIN) • HINT:


- for the two “L” drugs = 2 (pick the lower number)

• used to basically treat 2 things:

a) A-fib 
 - the other one’s = 20 (pick the higher #)
-> remember the ABCD’s of treating atrial arrythmias

b) congestive heart failure Kernicterus & Opisthotonos:
• therapeutic level = 1 - 2 • kernicterus = bilirubin in the brain when it crosses
the BBB (condition) -> is in the brain, in the CSF, in
• toxic level = > 2

*** NOTE: both have 2! -> so if the question uses the 
 the meninges

value of 2, call it toxic (safer to call something 
 - different from jaundice = yellow color from too much 

toxic when it may not be than to say that it’s 
 bilirubin in the skin

therapeutic when it might not be) - usually occurs when you reach levels of 20

- bili in the brain causes aseptic meningitis & aseptic 

• take the apical heart rate before giving Dig
encephalitis; can be lethal
3. AMINOPHYLLINE • opisthotonos = position the baby assumes when
they have bilirubin in the brain

• airway antispasmodic

- technically not a bronchodilator -> it doesn’t 
 = severe hyperextension due to the irritation of the 

stimulate beta-2 agonist cells to bronchodilate
 meninges w/ the bilirubin

- it just relaxes a muscle spasm
 -> newborns have high flexibility so when they 

-> in spasms = airway is narrow
 hyperextend they’re heels will touch their ears & 

-> when you relax a spasm, airways widen (which 
 they will be rigid

is why it looks like a bronchodilator)
 -> if you see a kid w/ levels of 15 extending the 

* ex. epinephrine is a bronchodilator neck they need follow-up immediately (medical 

emergency)
• ex. sometimes PT’s come in w/ an acute asthamatic
attack & the bronchodilators aren’t working -> because • ex. In what position do you place an opisthotonic
they are in an acute, lock-down spasm & the spasm is in child? = on their side
the way of the bronchodilator

= give them aminophylline first to relieve the spasm

= then you can give the bronchodilator after and it 

will work
• therapeutic level = 10 - 20
• toxic level = > 20

4. DILANTIN (PHENYTOIN)
• anticonvulsant; treat seizures
• therapeutic level = 10 - 20
• toxic level = > 20
ABDOMINAL • Three things to play around w/ to effect stomach
DUMPING SYNDROME vs. HIATAL HERNIA emptying time:

• both gastric emptying issues & are kind of opposites
 a) change the head of the bed

-> memorize one & you have the other 
 b) change the water content of the meal

c) change the carbohydrate content of the meal
Hiatal Hernia: Gastric Emptying HIATAL HERNIA DUMPING
• regurgitation of acid into the esophagus because the Issue Treatments SYNDROME
upper part of your stomach herniates upward through Head of Bed - HIGH position 
 - LOW position (lie 

during & after 
 flat and turn to 

the diaphragm
 meals (gravity 
 side to eat)
- your stomach should stay in the abdominal cavity helps empty faster)
• w/ this, you have a 2-chamber stomach (like having 
 Water Content - high fluids - low fluids (don’t 

give fluid w/ the 

2 stomachs) -> band around the middle meals -> an hour 

• gastric contents move in the wrong direction at before or after)
the correct rate
 Carb Content - high carbs 
 - low carbs to help 

because they go 
 stomach empty 

-> rate is not the problem, it’s the direction
 through faster slow
-> going the wrong way on a one way street Protein? - low protein - high protein
• S & S:

• Hint: Whatever carbs is, protein is the opposite.
- just plain GERD (gastro-esophageal reflux disease)

-> heartburn & indigestion

*** but just because you have GERD doesn’t 

mean you have hiatal hernia

- hiatal hernia is GERD when you lie down after 

you eat (the GERD only occurs after lying down)

- you cannot have hiatal hernia if your symptoms 

occur before lying down because hiatal hernia is 

dependent on position & meal time
• Treatment:

—> goal = want the stomach to empty faster

* because if it’s empty, it won’t reflux

** see table


Dumping Syndrome:
• gastric contents dump too quickly into the duodenum

- usually follows gastric surgery
• gastric contents move in the right direction at the
wrong rate

-> the rate is the problem
-> speeding
• S & S:

** long list of issues so take what you know & 

combine them to equal dumping syndrome

- drunk person -> staggering, slurring, impaired 

judgment, delayed reactions, labile emotions

-> from decreased blood flow to the brain because 

all the blood is going to the gut (because it 

dumped into the duodenum)

- shock -> classic sigs such as hypotension, 

tachycardia, tachypnea, pale, cold & clammy

- acute abdominal distress -> cramping pain, 

doubling over, guarding, borborygmi, diarrhea, 

bloating, distention, tenderness

- so, think drunk + shock + acute abdominal distress
• Treatment:

—> goal = want the stomach to empty slower

** see table
ELECTROLYTES • If it is skeletal muscle or nerve, blame it on Ca

• to know the S & S of electrolyte disorders, memorize -> for everything else blame it on K+

3 sentences:
 - ex. Your PT has diarrhea. What caused it?

a) Kalemia’s (K+ imbalances) do the same as the 
 a) hyperK+ -> same as prefix so could be this

prefix except for heart rate & urine output. (write 
 b) hypoK+ -> things go down so not this one

arrows to help)
 c) hypoCa -> opposites of prefix so could be this

b) Calcemias (Ca) do the opposite of the prefix.
 d) hypoMg -> opposites of prefix so could be this

c) Magnesemias do the opposite of the prefix. ** in a tie, don’t pick Mg; if it’s not skeletal or 

nerve you rule out calcium

• Kalemia’s do the same as the prefix except for ** Hint: when answering these kinds of questions, 

heart rate & urine output: 
 draw arrows! (i.e. diarrhea is an “up” symptom)

- look at the prefix: hyperK+ & hypoK+ (high & low)
 —> if the question had asked about tetany use the 

- symptoms will go HIGH w/ HYPER, LOW w/ HYPO
 sentences (prefixes), arrows & tie breakers to 

-> except for the heart rate & urine which goes 
 help rule out options & because it’s muscle & 

opposite the prefix
 nerve related, it’s hypoCa
S & S HYPER K+ HYPO K+ • Common mistake in electrolytes:

Brain irritability, aggitation, lethargy, ex. Your PT has tetany. What caused it? (tetany is the 

restlessness, agressions, obtunded, stupor body going up)

obnoxiousness, decreased
inhibitions, loud/boistrous a) a high K+ -> makes body go up

Lungs tachypnea bradypnea b) a high Ca -> makes body go down! (opposites) 

Heart LOW heart rate
 HIGH heart rate c) a low Mg -> makes body go up (but it’s a tie)

- T waves = peaked (tall)
 (tachycardia) —> 90% of students would pick Ca without properly 

- ST wave = elevated

*** everything else about the 
 looking at the question because the question is 

heart aside from the rate go up going the other way (use the sentences & arrows)

Bowel diarrhea, borborygmi illeus, constipation
Muscle spasticity, increased tone, hyper- flaccidity, low
** don’t do the tie breaker first
reflexive reflexes • prefixes -> arrows -> tie breakers
Urine LOW urine output HIGH urine output
• ex. Your PT has hyperK+. Select all that apply:
 Sodiums:
a) dynamic illeus e) U wave (goes down) -> sign of cardiac depression
 • d e hydration

b) obtunded f) depressed ST wave

c) +1 reflex g) polyuria
 - hypernatremia
d) clonus h) bradycardia • o verload

• Hint: don’t forget, if you don’t know something don’t - hyponatremia
pick it (don’t over select) • dehydration & overload are opposites

-> think of the signs & symptoms of both situations
• Calcemias do the opposite of the prefix. 

- hyperCalcemia = body goes low
 • ex. In addition to a high K+, what other electrolyte
-> ex. bradycardia, bradypnea, flaccidity, lethargy, constipation
 imbalance is possible in DKA?

- hypoCalcemia = body goes high
 - hyperNatremia

-> ex. agitation, clonus, hyper-reflexive, seizure, tachycardia -> because of dehydration
• Trousseau’s sign = put BP cuff on the arm and watch
to see if the hand spasms when it’s pumped up • Earliest (first) sign of any electrolyte disorder:

• Chvostek’s sign = tap the cheek -> watch for face = numbness & tingling -> paresthesia

spasms (hypocalcemia)
 ** circum-oral paresthesia (numb & tingling lips) is a 

- sign of neuromuscular irritability associated w/ low Ca
 very early sign
-> Hint: in hypoCa it does the opposite of the prefix 
 • UNIVERSAL SIGN of electrolyte imbalance is
so irritability would have to be hypoCa muscle weakness = ALL of them cause this

= paresis
• Magnesemias do the opposite of the prefix. 

- some review books say that hypomagnesemia is not 
 Treating Electrolyte Imbalances:
associated w/ hypertension BUT it is • the only one that really gets tested is K+

-> remember, high K+ is the most dangerous because 

• Could it be possible that certain symptoms could be it can stop your heart
caused by either a K+, Mg, or Ca imbalance? YES • Rules:

(How do you break the tie?)
 a) Never push K+ IV

- in a tie, don’t pick Mg because it’s not a major player b) Not more than 40 of K+ per L of IV fluid

-> call and clarify if there is an order for more 

(question the order if it’s over 40)

 c) Give D5W w/ regular insulin (K enters early)

- fastest way to lower K+

-> this will drive the K+ into the cells out of the 

blood (it’s the K+ in the blood that kills you, not 

the ones in the cells)

-> this doesn’t get rid of the extra K+ but it hides it 

well (doesn’t really solve the problem BUT it 

saves their the PT’s life)

*** buys time to solve the underlying problem 

(but if you don’t fix it the K+ will eventually 

leak back into the blood) - temporary fix

d) Kayexalate (K exits late)

- full of sodium; sits in the gut

- route: oral ingestion or rectal enema

- trades sodiums for K+ so you can poop out K+

-> PT ends up w/ high sodium (hypernatremia)

*** which is then dehydration which is easier to 

treat (trading a life-threatening imbalance w/ 

a non life-threatening one BUT the PT will 

still have an electrolyte imbalance)

-> pro's of kayexalate = get’s rid of excess K+ 

permanently as it leaves the body

-> con’s of kayexalate = takes a long time (HOURS) 

& the PT may not live that long


• best way to get rid of K+ to fix the imbalance by using

both D5W w/ reg. insulin + Kayexalate


LECTURE 7 -> first way - ice packs

-> best way - cooling blanket

ENDOCRINE -> O2 per mask at 10L (BUT, remember they are 

psychotic so good luck keeping that mask on)

• focus on the thyroid & adrenal glands -> what you
need to know most for the test ** maybe pick this first if picking between O2 & 

ice packs

• Hint: change the word ‘thyroid’ to ‘metabolism’ (the
thyroid regulates metabolism) - will come out of it themselves or die -> self-limiting

- don’t medicate

THYROID - 2 on 1 (need 2 people to care for these PT’s)

Hyperthyroidism:
Post-Op Risks:

• a.k.a. hypermetabolism
—> depends on type of surgery & timeframe (HAVE 

• think of all the S & S that you would see in a high
metabolism such as:
 TO KNOW THIS)
- weight loss, high BP & heart rate, anxious & irritable, 
 • 1st 12 hours:

hyper, heat intolerance (cold tolerance), exophthalmus
 a) does not matter if total or partial; priority is airway

-> think Don Knotts
 - thyroid is in the neck

- called Grave’s disease (run yourself into the grave) - any edema can cause constriction of airway

• 3 treatment options for too much hormone:
 b) hemorrhage

a) radioactive iodine
 - endocrine gland -> has a lot of blood vessels
i. PT should be in a room by themselves for 24 hrs. 
 • 12-48 hours:

-> no visits for the first 24 hrs.
 - need to pay attention to the type of thyroidectomy

ii. after that, PT needs to be extra careful with their 
 a) Total = tetany due to the low Ca

urine (i.e. flush 3 times after voiding, if urine spills 
 - can cause constriction of airway

on the floor the hazmat team must be called)
 b) Sub-total/Partial = thyroid storm
-> radioactive material is excreted via urine
 • after 48 hrs:

-> biggest risk to nurse is the urine
 - big risk is infection

b) PTU -> Propylthiouracil
 *** but never pick infection in the first 72 hours
- “puts thyroid under” = slows thyroid down

- primary use as a cancer drug BUT is used 
 Hypothyroidism:
specially for hyperT
 • a.k.a. hypometabolism
- nursing role:
 • think of all the S & S seen in low metabolism:

-> be aware that it is an immunosuppresent so 
 - obese (weight gain), flat/boring personality, cold 

WBC count needs to be monitored
 intolerance (heat tolerance), low BP & heart rate

c) Thyroidectomy (most common way)
 - called Myxedema
- partial or total removal -> PAY ATTENTION TO 
 • treatment option for not enough hormone:

THIS IN THE TEST (most important)
 - give thyroid hormones -> Synthroid (levothyroxine)
- total = need lifelong hormone replacement
 • DO NOT SEDATE THESE PT’S - because they’re
-> at risk for hypocalcemia (because of 
 body is already super slow & you could put them into
parathyroid, hard to save it in a total)
 a coma = myxedema coma

-> check Trousseau’s & Chvostek’s
 - question any pre-op orders that have sedation (i.e. 

- sub-total = don’t need lifelong replacement 
 Ambien before surgery)

because but may need it for a bit before the 
 - if PT is NPO before surgery you need to call the MD 

leftover thyroid starts “kicking in”
 because they need to be able to take their morning 

-> less risk for hypocalcemia
 thyroid hormone PO (never hold thyroid pills pre-

-> at risk for thyroid storm/crisis; 
 op without express order to do so)

thyrotoxicosis (total’s never get this) -> if no hormone replacement they will be 

hypothyroid & that will cause issues when being 

• Thyroid Storm:
 given sedative agents (anesthetics) for surgery
1. super high temps. (105 & up)

2. extremely high BP’s (stroke category; ex. 210/180)

3. severe tachycardia (ex. could be in the 180’s)

4. have psychotic delirium

—> MEDICAL EMERGENCY!!! can cause brain 

damage (can fry the brain to death)

- immediate treatment = get the temperature down & 

get the O2 up 

ADRENAL CORTEX • ex. PT w/ acute COPD exacerbation on Solu-Medrol
• coincidentally, these diseases start with the letter A or (a steroid) IV push Q8 to reduce inflammation in the
C (like the initials of adrenal cortex)
 airway. What nursing action needs to be taken on this
- ex. Grave’s would not be one, Cushing’s would PT? = Accu-Chek’s Q6 because of the high glucose!

-> steroids make glucose go up EVEN IF you’re not 

Addison’s Disease: a diabetic
• under-secretion of the adrenal cortex
 • Treatment:

- one of the rarest endocrine disorders - adrenalectomy (classic treatment for hyper-

• S & S:
 secretory glands is to cut it out)

a) hyper-pigmented
 -> bilateral adrenalectomy (remove all)

- very tanned (look healthy)
 -> but then this causes you to have Addison’s which 

b) do not adapt to stress (don’t have regulation of 
 means you have to have steroid treatment 

stress response)
 (which makes you look like “Cushman” all over 

- when stressed, BP will go down & glucose will 
 again which is the reason you got the adrenals 

down which will put them into shock
 removed in the first place)

** the purpose of the stress response is perfuse 
 -> takes about 1-2 yrs. just to get equilibrated back 

the brain w/ blood (raise BP) & give the brain 
 to feeling normal
glucose (raise glucose)
• Treatment:
 • endocrine surgery creates the opposite problem 

- steroids (because they’re low in steroids)

-> glucocorticoids

** all steroids end in ‘-sone’

-> in Addison’s you “add a -sone”

Cushing’s Syndrome:
• over-secretion of the adrenal cortex

- “cushy” sounds like you have more of something
• S & S:

** HAVE TO KNOW THIS

** gives you 2 things: the S&S of Cushing’s & the 

side-effects of steroids

** draw a picture of a little man (a.k.a. Cushman)

- moon face with a beard

- big big body w/ a bump on the front & the back

- skinny arms & legs

- fill him full of water & write ‘Na’ inside (put K+ 

outside of the body)

- draw striae on his abdomen (stretch marks)

- write ‘high glucose’ (MOST IMPORTANT)

- draw bruises

- word bubble = “I’m mad. I have an infection.”

a) moon face

b) hirsutism (lots of excess hair)

c) central obesity

d) bumps = gynecomastia & kyphosis (buffalo hump)

e) atrophy of extremity muscles

f) retains Na & water (thus, losing K+)

g) stretch marks

h) hyperglycemia (look like diabetics)

i) easily bruised

j) easily irritable

k) immunosuppressed
• ex. If you’re on a steroid and you’re a diabetic,
what do you do?

- need a lot more insulin (because steroids increase 

the blood glucose)
CHILDHOOD DEVELOPMENT • 9 - 12 months:

• children’s toys -> how to select the appropriate play - working on vocalization

activity/toy given the age of the child - best toy = speaking/talking toys

• 3 things to consider:
 -> ex. tickle me Elmo, talking books

- Is it safe?
 - purposeful activity w/ objects (at least 9 months)

- Is it age appropriate?
 -> ex. building w/ blocks

- Is it feasible? -> Hint: Never pick an answer w/ the following 

words if the kid is under 9 months = build, sort, 

Safety Considerations: stack, make, construct (because they are 

• a) no small toys for children under 4
 “purpose words”)
- no small parts that can be aspirated for under 4 • Toddlers -> 1 - 3 years:

• b) no metal toys if oxygen is in use
 - working on gross-motor skills

- because of sparks
 -> running, jumping

- might use the word “dye-cast” instead of metal (ex. 
 - best toy = push-pull toys

hot wheels car) -> ex. wagons, lawnmowers, little strollers

• c) beware of fomites
 - if it takes finger dexterity, then DO NOT choose it for 

- fomite = non-living object that harbours microorganisms 
 the toddler

** vector/host is the name for living
 -> ex. no colored pencils, no blunt scissors

- toys are notorious fomites on a pediatric unit (kids 
 - finger-painting is appropriate (should be called 

stick them in their mouths)
 “hand” painting) -> is not a dextrous activity, it is 

- worst fomite = stuffed animals
 gross motor

- best kinds of toys -> hard plastic toys (because you 
 - parallel play = play alongside others but not with
can terminally disinfect them)
 • Preschoolers: 

- ex. If you have a child who is immunosuppressed, 
 a) working on fine-motor skills

what would be the best toy for them? -> a hard 
 -> things that use finger dexterity

plastic action figure b) working on balance

-> ex. tricycles, tumbling, skating, dance class

Feasibility: -> swimming is more of a gross motor skill because it 

• “could you do it” in a certain situation doesn’t take balance (can start this w/ infants)

• ex. Is swimming a good/safe activity for a 13 yr. old? YES

ex. Is swimming an age appropriate activity for a 13 yr. old? YES

- co-operative play = play w/ others

ex. Is swimming feasible for a 13 yr. old in a body cast? NO - pretend play = highly imaginative at this stage
• use common sense • School-aged:

- characterized by the 3 C’s

Age Appropriateness: a) creative = let them make it (don’t make it & give it 

• this is what mostly gets tested
 to them)

-> if the test gives you a certain age, you need to 
 -> better to give them blank paper & crayons 

know what toy/activity to give them instead of coloring book so that they can create 

• 0 - 6 months:
 their own pictures

- children at this age are sensory-motor
 -> LEGO age! (let them create the trucks and cars 

- best toy = musical mobile
 instead of giving them toy cars)

-> something that stimulates BOTH sensory & motor
 b) collective = they like collecting things

- if they don’t have mobile as a choice, look for 
 -> etc. beanie babies, pokemon, barbies

something that is large & soft c) competitive = like to play games where there is a 

• 6 - 9 months:
 winner & a loser

- working on skills of object permanence (the idea 
 -> preschoolers want games where everyone is the 

that something is still there even if you can’t see it)
 winner & everyone gets the same prize
-> play at this age should be teaching them this
 • Adolescents:

- best toy = “cover-uncover toy”
 - peer-group association = they want to hang out 

-> choose something easy to cover & uncover (i.e. 
 with their friends and fit in

jack-in-a-box, pop up toys, books with movable 
 - if you have a question stating that there are a group 

parts that cover/uncover)
 of teenagers hanging out in one teenager’s room you 

- peek-a-boo, putting blanket on head & pulling off
 let them unless 1 of 3 things is happening:

- 2nd-best toy = something large & hard
 a) if anyone is fresh post-op (under 12 hrs.)

- worst toy for this age is the musical mobile (because 
 b) if anyone is immunosuppressed

they can pull themselves up, pull the mobile and 
 c) if anyone has a contagious disease
strangle themselves)
NEURO b) Do not let PT sit for longer than 30 mins

LAMINECTOMY - question this typical post-op order: up in chair for 

• lamina = the vertebral spinous processes
 1 hr TID

-> the bumpy bones you feel on the spine
 -> in chair for meals is ok because usually meals 

ectomy = removal only last for 30 mins

• removing posterior processes of the vertebral bones c) PT may walk, stand & lie down w/o restrictions

• reason -> to relieve nerve root compression
 - restrictions only on sitting

- cut away some of the bone to relieve the pressure 
 -> jobs w/ sitting all day (i.e. admitting clerk) has 

on nerves (give nerves more room to exit) shown to have the most occurrence of back 

• a.k.a. decompression surgery issues/pain

S & S of Nerve Root Compression (3 P’s): Post-Op Complications:

• Pain • they depend on location!
• Paresthesia = numbness & tingling • cervical:

• Paresis = muscle weakness - # 1 complication is pneumonia (because breathing 

is affected)
• For Laminectomy questions, the most important • thoracic:

thing to pay attention to in any neuro question is - pneumonia -> can’t cough properly

LOCATION, LOCATION, LOCATION!!
 - ileus -> affected bowel function
- will determine symptoms, prognosis, & treatment
 • lumbar:

- LOCATION IS EVERYTHING IN NEURO - urinary retention -> affected bladder function

• 3 locations in Laminectomies:
 - issues w/ the legs
- cervical = neck
 • ex. You are caring for a PT w/ a lumbar oligodendrogliocytoma.
-> innervates the diaphragm (breathing) & arms
 What’s the #1 problem?

a) airway c) cardiac arrhythmia

- thoracic = upper back
 b) ileus d) urinary retention -> it’s lumbar

-> innervates abdominal muscles (cough 
 *** LOCATION LOCATION LOCATION
mechanism) & gut muscles (bowels)

- lumbar = lower back
 • typically, don’t have chest tubes w/ laminectomies
-> innervates the bladder & the legs
 BUT the anterior thoracic will have chest tubes

- means the surgery goes through the front of the 

Pre-Op Laminectomy: thorax to get to the spine so you need tubes in order 

• when you change the location, you change the to address pneumo/hemathorax
answer
• ex. What is the most important pre-op assessment for Laminectomy WITH FUSION:
a cervical laminectomy?
 • “with fusion” -> key word; means that a bone graft is
= breathing & if it’s not one of the choices, pick the 
 taken from the iliac crest

one that checks the function of the arms & hands - take some bone from your hip to fuse in between the 

• ex. What is the most important pre-op assessment for bones from where the disc was taken out (to keep 

a thoracic laminectomy?
 from grinding)
= coughing & bowel sounds
 • most laminectomies don’t have fusion

-> if abdominal muscle function is affected, PT won’t 
 - because usually it’s just the “wing thing” being taken 

be able to contract enough to cough properly out BUT if the disc is also removed, you need fusion
• ex. What is the most important pre-op assessment for • PT will have 2 incisions:

a lumbar laminectomy?
 a) hip

= bladder function (voiding, distention), or function 
 -> has the most pain, most bleeding & drainage (will 

of legs and feet have the JP/Hemovac drain)

-> post-op, this one causes the most problems

Post-Op Laminectomy: ** surgeons want to get rid of this incision because it 

• #1 post-op laminectomy answer on N-CLEX is log-roll
 costs more, has more risks, want to cut recovery 

-> for any spinal injury time/hospital stay in half, less drainage if gone -> 

• 3 other things to know about mobilizing PT’s after surgeons are using cadaver bones from bone banks 

surgery:
 (no more 2nd incision; risk for rejection is low)

a) Do not dangle these PT’s
 b) spine

- go from lying to immediate standing/walking
 -> highest risk for rejection

- they can sit on the edge of the bed long enough to 
 ** both have equal risk for infections
avoid orthostatic hypoTN but not more than that

Discharge Teaching for Laminectomies:
• very important!
• 4 Temporary Restrictions:

a) Do not sit for longer than 30 mins

- applies for 6 weeks

- Hint: if you have to guess long a restriction 

applies for something, you should pick 6 weeks 

(otherwise if you know what it is pick the it)

b) Lie flat & log roll for 6 weeks

c) No driving for 6 weeks

d) Do not lift more than 5 pounds for 6 weeks

- ex. gallon on milk
• 3 Permanent Restrictions:

a) Will never be allowed to lift objects by bending 

at the waist

- should lift with the knees (everyone should)

b) Cervical lam’s are not allowed to lift anything 

over their head

- for the rest of their life

- get step stools

c) No jerky amusement rides, off-roading, horse-

back riding etc. 


• the Laminectomy info can be used to get any

spinal cord questions right

- pay attention to the locations
 Name and Normal Priority Level if Abnormal
LECTURE 8 Info Range
pH 7.35 - D = in the 6’s (ex. 6.58)
7.45 i. nothing to hold

LAB VALUES ii. assess vitals (body goes down w/ the 

• you have to know the main ones but also know pH) to make sure they’re alive

iii. nothing to prepare BUT treat the 

which ones are more dangerous than others
 underlying cause (which only the MD 

can do)

-> need to know how to prioritize PT’s according to 
 iv. call MD faster than in any other case
lab values (not good enough to just know basics) BUN 8 - 25 A = if elevated it’s not a big deal 

(blood -> assess PT for dehydration

• scheme (priority levels):
 urea 

-> the value is abnormal BUT what priority is it?
 nitrogen) Hint: if they give an elevated blood value &
you have no clue what’s going on & they
A = not a priority/low priority; don’t do anything 
 nitrogen ask “for what would you assess them” 

waste -> dehydration is a great guess (because all 

about, not a big deal (don’t really need to report it)
 products in blood values go up from concentration)
B = need to be concerned but nothing you need to do; 
 the blood
HgB 12 - 18
 B = 8 - 11

just needs closer monitoring
 ** boards - assess for low HgB (bleeding, malnutrition)
tend to
C = crossed a line from low to high priority; it is 
 not go into C = below 8
critical, you have to do something about it 
 genders i. nothing to hold
(this is the ii. assess for bleeding
i. always hold (if there’s something to hold)
 normal
adult iii. prepare to give blood
ii. assess (focused)
 HgB) iv. call MD
iii. prepare to give
 Bicarb 22 - 26 A
CO2
 35 - 45 C = high but in the 50’s

iv. call whomever is appropriate
 * not for 
 -> PT will be dyspneic

D = highest priority that you can possibly have w/ a 
 COPD 
 i. nothing to hold
PT’s, reg. 
 ii. assess resp. status

lab value; do something STAT!
 PT’s iii. prepare to get PT to do pursed-lipped 

breathing (prolongs exhalation to get 

-> you cannot leave their bedside (you can leave 
 from rid of CO2)

the bedside of a “C” level if needed); get other 
 arterial iv. breathing usually fixes it so you don’t 

blood gas have to call

people to help

D = in the 60’s -> one of the criteria for 

resp. failure (MEDICAL EMERGENCY)
i. nothing to hold

• Hint: Assess before you do unless delaying doing ii. assess resp. status

puts your PT at higher risk! (ex. blood transfusion reaction)
 iii. prepare to intubate & ventilate

iv. call resp. therapy first then MD
- ex. you should put the HOB up first before doing resp. 

assessment because keeping a dyspneic PT flat on bed 
 Hematocrit 36 - 54
 B = elevated


 -> assess for dehydration
longer puts them at higher risk
 * 3X the
- DON’T FORGET TO SEE IF IT’S A FIRST vs. BEST question HgB (so
memorize
the HgB
& multiply
Name and Normal Priority Level if Abnormal by 3)
Info Range
PO2 78 - 100 C = low but still in 70’s

Serum 0.6 - 1.2 A 
 i. nothing to hold

Creatinine
 - never make a PT w/ high creatinine as 
 from ii. assess resp. status

(same as highest priority
 arterial iii. prepare to give O2

best Lithium) - probably have kidney disease BUT they 
 blood gas iv. most times the O2 administration 

indicator of are not going to die in the next 4 hours
 (not from works and you don’t have to call the 

kidney - only time you might call MD is if they’re pulse MD because the dyspnea goes away

function going for a test that has a dye in it (but still 
 oximetry) * hypoxic -> heart rate speeds up first and 

wait to call in the morning, not right away) when the heart can’t work hard anymore, 

INR (inter- 2 - 3’s C = anything that is 4 & above is
 the resp. rate goes up

national i. hold Coumadin 

normalized ii. assess bleeding
 D = if in the 60’s -> the other criteria for
ratio) iii. prepare to give Vit. K
 resp. failure (MEDICAL EMERGENCY)
(variation of iv. call MD i. nothing to hold

PT) ii. assess resp. status

iii. prepare to intubate & ventilate

monitors iv. call resp. therapy first then MD 

Coumadin * you can still put O2 during this time 

K+ 3.5 - 5.3 C = if lower than 3.5
 -> won’t solve the problem but will help 

i. nothing to hold
 keep them calm
not a good ii. assess the heart
 O2 Sat 93 - 100 C = anything less than 93
indicator of iii. prepare to give K+
 i. nothing to hold
something iv. call MD
 ii. assess them
specific, 
 iii. prepare to give O2 if really low
just that C = between 5.4 - 5.9 iv. don’t need to call MD if O2 goes up

something i. hold all K+
 * you better freak out though if in paeds it 

is wrong ii. assess the heart
 goes below 95

iii. prepare to give D5W + reg. insulin + 
 * anemia falsely elevates it (you should look 

Kayexelate
 for other indicators); dye procedures in 


 the last few hours also invalidates it w/ 

iv. call MD
 false elevation


D = if > 6 (this PT could die soon; do all the 

same as C but do it stat! & need more 

than 1 person)
Name and Normal Priority Level if Abnormal
Info Range
BNP should B = elevated BNP

(brain be under - you know they have CHF/watch them for 

natriuretic 100 CHF

peptide) - it’s not high priority because it indicates a 

chronic condition
best
indicator of
congestive
heart failure
Sodium 135 - 145 B = if abnormal then assess

- if high -> assess for dehydration

- if low -> assess for overload



C = if Na is abnormal and there is a
change in LOC (because it becomes a
safety issue)
WBC’s
 Total C = all of them -> if they go below their
* 3 counts 
 WBC
 thresholds
that you 
 5,000 - i. nothing to hold
must 
 11,000
 ii. assess for signs of infection
know 
 iii. instead of preparing, place them on 

ANC neutropenic precautions
(absolute
Neutrophil
count)

needs to
be above
500


 -> if it falls below you go from HIV to AIDS
CD4

needs to
above
200
Platelets C = below 90,000

-> bleeding precautions
D = below 40,000
RBC’s 4-6 B
million
• memorize the 5 D’s => highest priorities!

- pH in the 6’s

- K+ in the 6’s

- CO2 in the 60’s

- O2 in the 60’s

- platelet below 40,000

—> boards doesn’t really put these kind of PT’s 

against each other because it’s not fair
• learn the C’s
LECTURE 9 BENZODIAZEPINEs:
• anti-anxiety meds
PSYCHOTROPIC DRUGS • considered to be minor tranquilizers (primary use)
• even though there are several classes, info tends to overlap • they always have “-zep” in the name

• ALL psych drugs cause low BP & weight changes
 -> both major & minor tranquilizers have “Z’s”
-> usually weight gain (but a few cause weight loss) • ex. Diazepam (Valium), Xanax, Clonazepam, Lorazepam
• for most of these meds, you need to take take them • indications: are more than just minor tranquilizers

for 2-4 weeks before you get beneficial effect
 a) pre-op to induce anesthesia

- many PT’s say that they don’t work after only taking 
 b) muscle relaxant

them for 1 week (nurse teaching) c) good for alcohol withdrawal

d) seizures

PHENOTHIAZINEs: e) help people when they are fighting the ventilator 

(relax & calm down)
• old class of drugs -> 1st gen/typical anti-psychotics
• ALL end in “-zine” • work quickly but technically, you shouldn’t take them
for more than 2-4 weeks
• actions:

- do not cure psych diseases -> reduce the symptoms
 • relationship between an anti-depressant & a minor
- in large doses they are anti-psychotics 
 tranquilizer?

-> “-zines for the zany”
 - one takes 2-4 weeks and you can be on it for the 

- in small doses they are anti-emetics
 rest of your life (anti-depressant)

- considered major tranquilizers
 - the other works quickly but you should only be on it 

-> Aminoglycosides are to antibiotics as 
 for 2-4 weeks (minor tranquilizer)

Phenothiazines are to tranquilizers = THE BIG 
 —> a lot of PT’s get put on both when first admitted as the 

minor tranq. will work right away & then when the anti-

GUNS (when nothing else is going to work)
depressant kicks in, they are taken off the minor tranq.

• major side effects (not toxic effects):

A = anti-cholinergic (primarily dry mouth)
 * heparin is to warfarin as a tranquilizer is to 

B = blurred vision
 an anti-depressant
C = constipation
 • side effects:

D = drowsiness
 A = anti-cholinergic (primarily dry mouth)

E = EPS -> extrapyramidal syndrome (looks like 
 B = blurred vision

Parkinson’s)
 C = constipation

F = photosensitivity
 D = drowsiness
aG = agranulocytosis (low WBC count, 
 • # 1 nursing diagnosis is risk for injury (safety issues)
immunosuppressed)

** side effect vs. toxic effect nursing actions:
 MAOIs - MONOMINE OXIDASE INHIBITORS:
- side effect = teach PT, inform MD, keep giving 
 • anti-depressants (one of the first types developed)

med (& give drugs that can help alleviate)
 - don’t really use them much anymore because of the 

- toxic effect = hold drug, call MD immediately restrictions & side effects

• the nursing care is treating the side effects
 - dirt cheap compared to other anti-depressants
- #1 nursing diagnosis for a client on a tranquilizer is 
 • you need to spot an MAOI when you see it on the test
risk for injury (safety issues) from the beginning of the name

• decanoate = long-acting IM form given to non- —> the beginnings of the name rhyme: Marplan, 

compliant clients
 Nardil, Parnate (all brand names)
- is something that may be court ordered • side effects:

A = anti-cholinergic (primarily dry mouth)

TRICYCLIC ANTI-DEPRESSANTS: B = blurred vision

C = constipation

• old class of anti-depressants & most have been
D = drowsiness
grandfathered into a newer class:

- NSSRI = non-selective serotonin re-uptake inhibitor • the important thing is patient teaching:

a) to prevent severe, acute, sometimes life-

• are mood elevators used to treat depression

threatening hypertensive crisis (high BP)

= “happy pills” 

- PT must avoid all foods containing tyramine (an 

- include Elavil, Tofranil, Aventyl, Desyrel
amino acid that regulates BP)

• side effects:
 -> NO aged cheese (can have mozzarella & cottage 

A = anti-cholinergic (primarily dry mouth)

cheese), yogurt, cured/preserved/organ meats, 

B = blurred vision

alcohol, caffeine, chocolate, fermented foods, 

C = constipation

bananas, avocado’s (guacamole!), any dried fruit

D = drowsiness

E = euphoria b) do not take OTC meds when on an MAOI
LITHIUM: —> EPS = side effect (no big deal)

• used to treat bi-polar disorder
 —> NMS = medical emergency!!! (PT can die!)
-> it decreases mania (does not treat the depression) • How do you tell the difference between EPS &
• of all psych drugs, it’s the most unique (diff. side effects) NMS?? take a temperature

because all the other ones mess w/ neuro-transmitters
 -> no excuse for the nurse to miss NMS

-> Lithium does not = stabilizes nerve cell membranes -> first action when faced w/ a PT that has anxiety & 

• unique side effects that act more like an electrolyte:
 tremors = take their temp.

P = peeing P = pooping 
 ** if over 102 call emergency response team coz it’ll 

P = paresthesia -> earliest sign of all electrolyte imbalances be a bad situation (even if it’s not 105 degrees yet)
• TOXIC effects:
 • safety concerns related to the side effects:

—> hold & call the MD
 - as soon as they get hit by Haldol, they go down
- tremors - metallic taste - severe diarrhea
• Interventions for PT’s on Lithium:
 CLOZAPINE (CLOZARIL):
a) #1 = increase fluids
 • prototype 2nd gen/atypical anti-psychotic

-> because they are peeing & pooping a lot so at 
 - new class for the “zany”
higher risk for dehydration
 • used to treat severe schizophrenia
b) watch Na levels
 • was meant to replace the “-zines” & Haldol

c) if they are sweating like crazy don’t give free water, 
 - advantage is that it does not have the side effects 

give Gatorade or some other electrolyte solution
 A B C D E or F

-> PT has to have a normal Na for Lithium to work
 - has slight effects but minor compared to “-zines” 

d) NOTE: Lithium is closely linked to sodium.
 - BUT does have side effect aG (agranulocytosis)

- low Na = makes Lithium more toxic
 -> horrendous in trashing bone marrow

- high Na = makes Lithium ineffective
 -> causes unbelievably low WBC counts causing 

*** need normal Sodium levels
 you to get horrible infections
• other variations created that have less aG effects but still
PROZAC -> SSRI - SELECTIVE SEROTONIN RE- have to monitor them
UPTAKE INHIBITOR: • not everyone gets the low WBC so some people can
• similar to Elavil (NSSRI) take it but some people can’t
• side effects:
 • nursing priority = monitor WBC counts
A = anti-cholinergic (primarily dry mouth)
 • Note: Geodon (Ziprasidone)

B = blurred vision

- has a black box warning -> prolongs the QT interval 

C = constipation

D = drowsiness
 & can cause sudden cardiac arrest

E = euphoria —> shouldn’t really use in PT’s w/ heart problems
• Prozac causes insomnia
 • in general, these drugs end w/ “-zapine”

-> give it before noon (bad idea to give at bed time) - another tranquilizer class that has a “z”
• When changing the dosage for a young adult/
adolescent, watch for increased suicidal risk
 SERTRALINE (ZOLOFT):
-> only this age group & only when there is recent 
 • another SSRI like Prozac
dosage change • also causes insomnia BUT you can give it at bedtime
• the big thing these days is testing the interactions:

HALDOL: a) cytochrome P450 system in the liver = major pathway 

• has a decanoate form (long acting IM) in which drugs are metabolized & deactivated in the liver 

• basically the same as Thorazine so side effects are:
 -> Zoloft is notorious for interfering w/ this system 

- A B C D E F aG (causes toxicities of other drugs because they 

are not getting metabolized) 

• is also an old 1st gen/typical anti-psychotic like the 
 -> whenever you add Sertraline to a PT’s drug 

“-zine’s” (major tranquilizer) regimen, you will probably have to lower the 

• the big thing they test for Haldol is NMS!
 dosages of the other drugs

- elderly PT’s & young, white schizophrenics may 

b) watch for interactions w/ St. John’s Wort

develop NMS w/ Haldol overdose
- you will get serotonin syndrome 

• NMS = neuroleptic malignant syndrome

-> potentially life-threatening

- potentially fatal hyper-pyrexia

-> looks like the MAO PT’s that eat the tyramine

- could reach 106-108 degrees (definitely over 105)

** SAD Head = sweaty, apprehensive, dizzy, headache

- dosage for elderly PT’s should be half the adult dose
c) interactions w/ Warfarin (Coumadin) 

• has anxiety & tremors (like EPS) & get both w/ it:

- if PT on both, they might bleed out (MUST reduce 

** boards will want to know if you know the 

Coumadin) -> watch for increased bleeding if on 

difference between them

both because Zoloft makes Coumadin go toxic
LECTURE 10 • 4 Positive Signs:

a) fetal skeleton on x-ray

MATERNAL NEWBORN b) fetal presence on ultrasound

PREGNANCY: c) auscultation of a fetal heart rate

-> starts beating at 5 weeks but you hear it 

• you must be able to calculate a due date

- take the 1st day of the last menstrual period
 between 8-12 weeks

- add 7 days, subtract 3 months
 d) when examiner palpates fetal movement/outline

-> not a positive sign when mom feels it (i.e. quickening)

- ex. PT’s last menstrual period was from June 10-15

** none of them have false positives
= due date is apx. March 17
• you need to know how much weight should/
• most OB information has a range where/when it
shouldn’t be gained:

occurs (because every woman is different)

** don’t worry about multiples or about women who 

-> because of this it is critically important that you 

are underweight/over-weight to begin w/

read OB questions carefully & properly
- Total weight gain = should be 28 lbs, +/- 3

• there can be 3 different questions for every fact in OB:

-> 1st T = 1 lb/month (3 lbs; too much is bad)

a) when would you first…

-> 2nd & 3rd T = 1 lb/week

-> pick the earliest part of the range

** on the test, if they give you a particular week of 

b) when is it most likely…

gestation, you have to be able to predict what the 

-> pick the mid part of the range

weight should be

c) when should you ___ by…

- ex. Woman in 28th week who has gained 22 lbs. 

-> pick the end of the range
What is your impression?
 ex. When should you first auscultate a fetal heart? = at 8 weeks

-> Week 12 (end of 1st T) = 3 lbs., after that, each 
 ex. When would you most likely auscultate fetal heart? = 10 weeks

week is 1 lb. 
 ex. When should you auscultate a fetal heart by? = by 12 weeks
-> she should have gained 19 lbs, she gained 3 
 *** PAY ATTENTION TO WHICH ONE THEY ASK!
more than supposed to
 • quickening = when the baby kicks -> 16 to 20 weeks

-> HINT: if you take the week & subtract 9, that is 
 - first feel = 16 weeks

the weight that should be gained
 - when is it most likely to feel = 18 weeks

* 12 - 9 = 3; 13 - 9 = 4, 20 - 9 = 11
 - when should you feel it by = 20 weeks
- being over 1-2 lbs. is ok but if she’s 3 lbs. off she 

needs further assessment
 • The MAYBE Signs: (probable’s & presumptive’s)

-> 4 lbs. or more off = could be trouble
 a) all urine & blood pregnancy tests

* ex. if PT is 6 lbs. underweight, she needs a biophysical 
 -> a positive pregnancy test is NOT a positive sign 

profile to make sure the baby is still alive
 of pregnancy (because it only means you have 

- ideal weight gain = week - 9 the hormones that go w/ pregnancy, but doesn’t 

• Fundal Height:
 mean you always have a fetus)

- fundus = the top part of the uterus
 ** which is why you can have false positives

-> not palpable until week 12 (after 1st T)
 b) Chadwick’s sign = cervical color change to 

- When is the fundus at the umbilicus?
 cyanosis (bluish; includes vagina & labia)

= 20-22 weeks of gestation
 Goodell’s sign = cervical softening

- it is important to know fundal location to recognize 
 Hegar’s sign = uterine softening

date of viability and know what trimester the PT is in:
 *** all occur in alphabetical order (boards tends to the 

= 20-22 weeks (24 is the end of the 2nd)
 order instead of the weeks they occur because 

** ex. if a PT is brought into ER and w/ history about the 
 weeks vary, order doesn’t)
pregnancy (or she can’t tell you), you need to know what 

trimester she’s in to know what’s going on with the baby
 Patient Teaching in Pregnancy:
-> fastest way to know the trimester = palpate the 
 • teaching PT’s the pattern of office visits

fundus (if you don’t feel it at all, she’s in the 
 *** good prenatal care is a major factor in infant 

1st T & she is the priority, not the baby)
 mortality so teach women how often to come in for 

-> if you feel the fundus at/below the 
 good prenatal care

bellybutton she’s in 2nd T (she is still priority)
 a) once a month until week 28

-> if the fundus is above the umbilicus she is in 
 - for all of 1st & 2nd T

the 3rd T and baby is the priority! - for the early part of 3rd T

b) once every 2 weeks until week 36

Signs & Symptoms of Pregnancy: c) once every week until delivery or week 42

• probable, presumptive, positive -> BUT on the test - by then, schedule for induction/c-section
there is only POSITIVE & everything else (maybe’s)
• ex. If a woman comes in for her 12th week checkup, -> ischial spines = the smallest diameter through 

when does she come in next?
 which the baby has to fit for a vaginal birth (the 

= week 16
 tight squeeze, the narrowest part of the pelvis)

ex. If she comes in for her 28th week checkup?
 ** if the baby cannot fit through there, the baby 

= week 30 (& then 32, 34, 36)
 cannot be born vaginally

ex. If she comes in for her 36th week checkup?

-> negative stations = the head/presenting part is 

= week 37, 38, 39, 40, 41, 42, take the baby
above the “tight squeeze” 

* negative news

• teach her that her hemoglobin will fall:

-> positive stations = the presenting part is below 

- we don’t worry about low HgB unless it gets really low

the ischial spines and has already made it through 

- normal HgB for females = 12 - 16

the “tight squeeze

-> 1st T - can fall to 11 & be perfectly normal (not 

* positive news

considered low)

** ex. if the baby’s head stays at -1 & -2 for 17 

-> 2nd T - can fall to 10.5 & be normal
 hours after fully dilated & 100% effaced, the 

-> 3rd T - can drop to 10 & still be called normal
 head is too big and PT needs a C-section

** acceptably low can be as low as 9
 ** ex. if the baby’s head stays at +3 for 17 hours, 

- tolerate lower HgB’s in pregnant women the further 
 the baby can still be born vaginally but needs a 

along they are than you would w/ non-pregnant PT’s vacuum extractor, forceps, or an episiotomy

- engagement = station 0 

• teaching about the discomforts of pregnancy:
 -> the presenting part is at the ischial spines

a) morning sickness = 1st T problem
 - lie = relationship of the spine of the mother & the 

- treat by eating dry carbohydrates (ex. crackers) 
 spine of baby

BEFORE you get out of bed
 -> longitudinal lie = parallel to mom’s spine (good!)

b) urinary incontinence = 1st & 3rd T problem
 -> transverse lie = perpendicular, sideways (spines 

- why not the 2nd? the baby is an abdominal 
 at a right angle); looks like a T; bad, trouble

pregnancy at this point and off the bladder
 -> oblique lie = baby is diagonal into mom’s hip 

- treat by voiding every 2 hrs (should do this from 
 instead of straight into the pelvis

the start of pregnancy until 6 weeks after delivery)
 - presentation = the part of the baby that enters the 

c) difficulty breathing = 2nd & 3rd T problem
 births canal first

- teach tripod position (like COPD clients)
 -> ROA, LOA etc.

d) back pain = usually 2nd & 3rd T
 -> don’t spend a ton of time memorizing the 

- tends to get worse and worse the further along you 
 presentations (this is a hard OB question; know 

get in the pregnancy
 the stuff that everyone needs to know!)

- treat w/ pelvic tilt exercises (tilt pelvis forward)
 ** you cannot miss the easy ones!

* ex. put foot on stool -> the most common ones are ROA & LOA (right & 

left occiput anterior)

• pregnancy questions are a good place for using ** you have much better chances guessing by 

common sense because it is not a disease, it’s a picking one of these (R before L)
healthy state

-> using good health patterns 
 Stages of Labour & Delivery:
-> if you get a question you don’t know, ask yourself 
 • 1 = Labour (all of it)

“what would be good for anybody?” & pick that answer - 3 Phases of Labour:

a) Latent b) Active c) Transition

LABOUR & BIRTH Phases LATENT ACTIVE TRANSITION
• what is the truest, most valid sign that a woman is Dilation 0 - 4 cm 5 - 7 cm 8 - 10 cm
in labour???
 Contraction
 every 5 - 30 every 3 - 5 every 2 - 3
FREQUENCY mins. mins. mins.
= onset of regular, progressive contractions
 Contraction 15 - 30 30 - 60 60 - 90
—> not bloody show or water breaking (you can have 
 DURATION seconds seconds seconds
these and not be in labour) Contraction “mild” “moderate” “strong”
INTENSITY
• Terminology:
 Hint: memorize the middle column (active
- dilation = the opening of the cervix
 labour) because everything is sequential



-> goes from 0 - 10 cm
 NOTE: contractions should not be longer
-> 0 = closed; 10 = fully dilated
 than 90 seconds or closer than every 2
mins. —> means trouble in labour!

- effacement = thinning of the cervix
 - signs of uterine tetany, uterine hyper-

stimulation; parameters to stop Pitocin
-> goes from thick to 100% effaced

• ex. A woman comes into L & D. She is 5 cm dilated,
- station = relationship of the fetal presenting part to 
 contractions 5 mins. apart lasting for 45 seconds. What phase
mom’s ischial spines
 is she in? = active
• 2 = Delivery of the Baby Interventions for ALL Other Complications in
• 3 = Delivery of the Placenta Labour & Birth:
• 4 = Recovery
 • ex. include uterine atony, uterine hypoTN, vena cava
- 2 hours syndrom, uterine tetany…etc.
• What is the purpose of uterine contractions in:
 • all treated the same, treated with LION:

- 1st stage = dilate & efface the surface
 L = 1st, turn them on their left side

- 2nd stage = push the baby out
 I = increase IV 

- 3rd stage = push the placenta out
 O = oxygenate them

- 4th stage = stop bleeding by contracting the uterus N = notify MD

• When does postpartum technically begin?
 ** RPN’s can do all except increase IV

= 2 hrs after delivery of the placenta - left side position is first but also probably best 

• DON’T MIX UP PHASE & STAGE! pay attention!
 because it addresses uterine perfusion which 

- ex. What is the #1 priority in the 2nd phase? 
 protects/saves baby
= pain management
 • PIT: in an OB crisis, if Pitocin is running, STOP IT!

- ex. What is the #1 priority in the 2nd stage?
 = this would become the first thing then before turning 

= clearing the baby’s airway
 them onto their left side
- ex. What are major nursing actions to take in the 3rd 

phase? = check dilation, help w/ pain & breathing

Pain Meds in Labour:
- ex. What are major nursing actions to take in the 3rd 

stage? = assessing blood loss, making sure there 
 • do not administer a pain med to a woman in
are 3 vessels in the cord, making sure the whole 
 labour if the baby is likely to be born when the
placenta comes out med peaks (review peaks lecture)

• Teaching PT’s how to time contractions:
 - ex. You have a primigravida at 5 cm who wants her 

- frequency = beginning of one contraction to 
 IV push pain med. Will you give it or not?

beginning of the next (A to C)
 -> is it likely that a primigravida at 5 cm will deliver 

- duration = beginning to end of 1 contraction (A to B)
 in the next 15-30 mins? NO, so give her the med

- intensity = strength of contraction -> subjective
 - ex. A multigravida at 8 cm wants her IM pain med. 

- teach her to palpate w/ one hand over the fundus 
 Do you give it?

with the pads of the fingers (fingertips) 
 -> is it likely that she could deliver in the next 30-60 

* use other hand to time it mins? YES, so no IM med for her

COMPLICATIONS OF LABOUR
• there are 18 that can occur in L & D that you need to
know BUT there are only 3 protocols you need to
know for all of them
• a) Painful Back Labour

- usually for OP positions (occiput posterior)

—> think “oh pain!”

- low priority

- do 2 things:

i. position = place her in knee chest position (face 

down on hands & knees, bum up in air)

-> to have baby come off the coccyx 

ii. push = take your fist and push it into her sacrum 

(applies counter pressure to relieve pain)
• b) Prolapsed Cord

- OB MEDICAL EMERGENCY!!! high priority!

- when the cord is the presenting part (comes out first) 

& so when the head comes down it presses on the 

cord and cuts of the supply causing baby to “kill itself”

- do 2 things:

i. push = baby’s head off cord (DON’T touch the cord)

ii. position = knee chest position to take 

compression off of the cord

** delivery is then usually emergency C-section (take 

mom to OR in knee-chest position while holding head)
LECTURE 11 STAGE 3 of LABOUR = Delivery of the Placenta:
• a) make sure it’s all there
MATERNAL NEWBORN continued • b) check for 3 vessel cord

FETAL MONITORING PATTERNS: - 2 arteries

- 1 vein
• 7 that you should know but easy to remember
• a) Low Fetal Heart Rate

= under 110
 STAGE 4 of LABOUR = Recovery:
- BAD! do L I O N & if Pit was running, stop it • is the first 2 hours after delivery of the placenta
• b) High Fetal Heart Rate
 • 4 Things you do 4 Times an hour in the 4th Stage: 

= over 160
 *** Q15

- not a big deal, not a high priority
 a) vitals signs

- document & take mom’s temperature
 - assessing for S&S of shock (pressures down, 

-> could be up because mom has a fever (so 
 rates up, pale, cold & clammy)

nothing wrong with baby) b) check the fundus

- if boggy -> massage

• c) Low Baseline Variability

= when the fetal heart rate stays the same & does 
 - if displaced -> catheterize

not change (whether high, low, or in the middle)
 c) check the perineal pads

- BAD! do L I O N - to see how much she is bleeding

- if excessive -> will 100% saturate in 15 mins. or 

• d) High Baseline Variability

= fetal heart rate is always changing
 less (so if 98% saturated, she’s still ok)

- good! document it d) roll her over

- check for bleeding underneath her

• once a person is born, if their vital signs stay the
same they are called stable BUT before you’re born, if —> also lets you assess the perinanal area
your vital signs stay the same it’s bad

-> we don’t want to see the opposites happen POSTPARTUM:
• assessments -> usually 4-8 hrs. depending on PT stability
• e) Late Decelerations

= heart rate slows down near the end or after a 
 • B = breasts

U = uterine fundus (want it firm, midline, height r/t 

contraction

to the bellybutton)

- BAD! do L I O N
-> should be going down 1 cm per postpartum day

• f) Early Decelerations

B = bladder

= heart rate slows down before or at the 

B = bowel

beginning of a contraction

L = lochia (rubra, serosa, alba)

- normal, no big deal; document it
-> rubra = red; serosa = pink; alba = whitish yellowish

• g) Variable Decelerations

E = episiotomy

- VERY BAD!!! this is what happens when you have 

H = hemoglobin & hematocrit

prolapsed cord -> push, position

E = extremity check 

- this is the most unique one
-> check for thrombophlebitis (via bilateral calf 

• 3 good 

circumference measuring)

3 bad = all start w/ an L -> L I O N

-> Homan’s sign is not the best answer because you 

1 variable = push, position can have it w/o having thrombophlebitis & vice 

• What causes the different heart rates?
 versa (not as reliable or valid)

V = variable C = cord compression
 A = affect (emotions)

E = early dec. H = head compression
 D = discomforts

A = acceleration O = it’s ok
 ** 3 big things tested in postpartum are the uterine 

L = late dec. P = placental insufficiency fundus, lochia, & extremities
• What answer always wins in a tie??

- in OB = check fetal heart rate Variations in the NEWBORN:
• review all the normal’s
STAGE 2 of LABOUR = Delivery of the Baby:
• know difference between:

• all about order:
 - caput succedaneum = c.s. -> crosses sutures

1 = deliver head
 -> symmetrical

2 = suction the mouth first, then nose
 - cephalohematoma = bleeding
3 = check for nuchal cord (around the neck)
 • normal physiologic jaundice -> appears after 24 hrs.
4 = deliver the shoulders & the body • pathologic jaundice -> baby comes out yellow
• the baby MUST have an ID band on before it
leaves the delivery area
OB MEDS:
• don’t have to be an expert; just know general info
what they are & a few main things about them

—> 6 main meds
• Tocolytics = stops labour (threatening prematurity)

a) Terbutaline

- causes maternal tachycardia

b) Magnesium Sulphate

- watch for TOXICITY

- watch for hypermagnesemia (everything down)

-> heart rate down

-> BP down

-> hypo-reflexive (want to keep it +2)

-> resp. rate down (want at least 12 resps.)

-> LOC goes down

*** boards likes to test reflexes & resp rate most

- closely monitor the PT’s reflexes & resp. rate
• Oxytocics = stimulate/start & strengthen labour

c) Pitocin

- can cause uterine hyper-stimulation (i.e. 

contractions longer than 90 seconds, closer than 2 

mins. apart -> BAD!)

d) Methergine

- causes high BP (contracting -> vasoconstriction 

raises BP)
• Fetal Lung Maturing meds:

e) Betamethasone - a steroid

i. mom gets it

ii. given IM

iii. given before baby is born

- can be repeated as long as baby is in utero

f) Survanta (Surfactant)

i. baby gets it

ii. given transtracheal (blown in through trachea)

iii. given after baby is born
MEDICATION HELPS & HINTS PEDIATRIC TEACHING
• to help get basic facts down • review of Piaget’s theory of cognitive development

• What is Humulin 70/30?
 -> won’t actually name Piaget but will ask questions 

= mix of N & R insulins
 on how you would teach children in order to test 

- 70 & 30 are percentages
 knowledge of the theory
-> 70 % is N
 4 Stages of Piaget (Cognition):
-> 30% is R • a) 0 - 2 years = SENSORY-MOTOR

• Can you mix insulins in the same syringe?
 - these kids are totally present oriented

= YES
 -> don’t think about past or future

- when you draw it up go clear to cloudy, R to N 
 -> only sense what they are doing right now

(“RN’s draw up RN”)
 - teaching: while/as you do it & teach them what you 

- when talking about pressurizing the vials you inject 
 are doing (think present tense)

air into N first, then R & draw up R, then draw up N - teach verbally -> just tell them (don’t understand 

• Injections:
 “play” yet)

—> will ask what needle to use for a particular injection
 - ex. when teaching a PT about a procedure, teach 

- IM = “I” looks like 1, pick the answer that has the 1’s 
 while doing it (won’t work to teach them ahead of 

in them (21 gauge…)
 time) -> no pre-op/post-op (except for the parents)
- SubQ = “S” looks like 5 • b) 3 - 6 years = PRE-OPERATIONS (think preschool)

- these kids are fantasy oriented

HEPARIN vs. COUMADIN: -> imaginative, illogical, thinking obeys no rules

• in the top 3 most commonly tested drugs! -> “you can’t reason w/ a preschooler”

HEPARIN COUMADIN - understand past & future so you can teach them 

Route IV or SubQ only PO before & after 

Onset works immediately takes a few days -> BUT has to be shortly before or after (ex. the 

to a week to work morning of, the day of, 2 hrs. before…)

Length cannot be given for longer can be given for
of Use than 3 weeks (except the rest of your life -> don’t give them too much time to get 

Lovenox)
 imaginations going on something 

- body starts making heparin
antibodies after 3 weeks - teaching: what you are going to do (future tense)

which can be life-threatening - teaching through play

Antidote Protamine sulphate Vit. K -> ex. the day of, teaching PT about lumbar puncture 

Lab Test PTT (partial thromboplastin PT -> INR by playing w/ equipment/dolls
that time)
monitors • c) 7 - 11 years = CONCRETE OPERATIONAL

can be given to pregnant cannot be given to - these kids are rule oriented

women pregnant women -> can’t think abstractly yet, rigid

• only major anti-psychotic that can be given to -> only one way of doing something

pregnant women = HALDOL -> “my teacher said”, or “my parents said”

- will tell you you’re doing something wrong if it was 

K+ Wasting & K+ Sparing Diuretics: different from the way a previous person did it (ex. 

• probably the only questions you’ll get about diuretics wound dressings by different nurses)

is whether if wastes or spares K+ - teaching: days ahead; what you’re going to do + skills

• any diuretic drug ending in “X” it waste’s K+
 - teach via age appropriate reading & demonstration
-> also Diuril
 • d) 12 - 15 years = FORMAL OPERATIONAL

*** otherwise, it spares K+ - can abstract think & think cause & effect

-> Hint: as soon as a kid hits 12 and they ask 

Baclofen: about teaching, it’s no longer a pediatric question 

• boards test muscle relaxants as a class and is an adult med-surge question (you teach 

• sore “back” -> if you’re on Baclofen, you’re on your them like an adult)

back loafin’ - ex. When’s the first age that a child can manage 

• 2 side effects:
 their own care? = 12

a) fatigue/drowsiness
 -> a 7 yr. old can do the skills related to their care 

b) muscle weakness but can’t manage; managing requires making 

• Patient teaching:
 decisions which require abstract thinking

a) don’t drink
 -> it’s not the severity of the illness that determines 

b) don’t drive
 who can manage it, it’s the age (ex. a 10 yr old w/ 

c) don’t operate heavy machinery scraped knee vs. 13 yr old w/ renal dysfunction)

• Flexeril -> the other muscle relaxant they test *** key word is manage (13 yr. old); skills = 7-11
7 PRINCIPLES of PSYCH
• 1. Make sure you know which phase of the 

relationship you’re in 

- pre-interaction, introduction/orientation, working, termination
• 2. Gift giving 

- NO GIFTS IN PSYCH (giving or receiving)

- ex. don’t accept flowers from a PT w/ schizophrenia 

because to you they might just be flowers but to 

them that might be a marriage proposal
• 3. Don’t give advice

- ex. If the PT asks “What do you think I should do?” 

you reply w/ “What do you think you should do?”

- you can give advice in med-surge or paeds
• 4. Don’t give guarantees
• 5. Immediacy

- if a PT says something, the best answer is the 

one that keeps them talking

-> don’t pick answers that say “refer to social work” 

because that shuts off communication right then 

and there

-> Hint: it’s never wrong to get your PT to talk
• f) Concreteness

- don’t use slang 

-> psych PT’s tend to take things literally

- if PT’s use made up words (neologism), those are 

not concrete so don’t use them
• g) Empathy

- you have to know empathy!!! -> all about feelings

- the best psych answers are the answers that 

communicate to the PT that the nurse accepts the 

PT’s feelings as being valid, real, & worthy of action

- bad answers:

-> “don’t worry” (because it tells them not to feel)

-> “don’t feel”, “you shouldn’t feel…”, “I would feel”, 

“anybody would feel”, “nobody would feel”, “most 

people feel”

Empathy Questions:
• recognize that it’s an Empathy question

- always have a quote in the question & each of the 

answers is a quote (i.e. PT says; what would you say?)
• put yourself in the client’s place

- you often have to read the feeling into the questions
• ask yourself: If I say those words (in an answer)
and I meant them, how would I be feeling after?
• go and choose the answer that reflects that
feeling (or anything close)

- DON’T choose the feeling that reflects the PT’s 

words

- empathy questions usually have a “sucker 

answer” (to sucker you into picking that one) & one 

of them is one that reflects/over-emphasizes what 

the PT said but ignores what the PT felt

-> you’re supposed to pick the answer that 

reflects what they felt (& ignores what is said)

* don’t mix this up
LECTURE 12 • 3 things that result in a black tag in an unwitnessed
accident: (tag them black & ship them last)

PRIORITIZATION, DELEGATION, STAFF MANAGEMENT - pulselessness

PRIORITIZATION: - breathlessness

• testing to see how you prioritize 4 different PT’s - fixed & dilated pupils -> brain death
• you are deciding which PT is sickest or healthiest
 • d) the more vital the organ, the higher the priority

- pay attention to which one you’re being asked for
 —> only use as a tie breaker

- ex. if question is asking “Who do you discharge?” 
 - talking about the organ of the modifying phrase (not 

-> asking for your lowest priority/healthiest client
 the diagnosis)

- ex. “Who would you assess/check first after report?” 
 - Order of Organ Vitality:

-> the highest priority/sickest client i. brain

• Priority answers always have 4 parts:
 ii. lungs

a) age
 iii. heart

b) gender
 iv. liver

c) a diagnosis
 v. kidney

d) a modifying phrase
 vi. pancreas

- ex. a 10 yr. old male with hypospadias who is throwing up 
 *** after that no one agrees
bile stained emesis

- 2 of these are irrelevant & you don’t need them in 
 DELEGATION:
your answer = age & gender
 • DO NOT delegate the following to RPN’s:

*** pay attention to age in paediatric teaching but in 
 a) starting an IV

prioritization questions, you don’t
 -> don’t assume they have IV certification 

- the modifying phrase is the most important
 b) hanging or mixing IV meds

** don’t get stuck doing ABC’s c) pushing IV push meds

** they can maintain & document IV flow

4 Rules for Prioritization: d) administer blood or mess w/ central lines

• a) acute beats chronic
 -> no flushing

- an acutely ill person is a higher priority -> if only option is “change central line dressing”, then 

• b) fresh post-op (12 hrs.) beats medical/other surgical pick that otherwise, they shouldn’t do that either

• c) unstable beats stable 
 e) cannot plan care

- know the words in a modifying phrase that mean 
 -> they implement, RN’s plan

stable & unstable
 f) can’t perform or develop teaching

STABLE UNSTABLE -> they can reinforce teaching

stable unstable g) can’t take care of unstable PT’s

chronic illness acute illness h) not allowed to do the first of anything

post-op greater than 12 hours post-op less than 12 hours -> should be the RN (because they can plan)

local or regional anesthesia general anesthesia i) cannot do the following assessments:

lab abnormalities of an A or B lab abnormalities of a C or D - admission

level level
“ready for discharge”, “to be “not ready for discharge”, “newly - discharge

discharged”, “admitted longer admitted”, “newly diagnosed”, - transfer

than 24 hours ago” “admitted less than 24 hrs. ago”
unchanged assessments changing/changed assessments
- the first assessment after there has been a change
PT is experiencing the typical PT is experiencing unexpected • DO NOT delegate the following to a nursing aid:

expected S&S of the disease S&S —> they are unlicensed personnel

with which they were
diagnosed - no charting

- don’t mix up symptom severity w/ unexpected symptoms 
 -> though, they can chart what they did but not 

(ex. PT w/ kidney stones having severe pain is lower 
 about the PT

priority than PT w/ mild chest pains when having an x-ray
 - can’t give meds

- 4 things that always make you unstable 
 -> except for topical, OTC barrier creams

(regardless of whether it’s expected or not):
 - no assessments (except for vitals & accu-checks)

i. hemorrhage (don’t confuse w/ bleeding)
 -> for cost reasons

ii. high fevers (over 105) -> risk for seizure
 -> watch for words like “evaluating”

iii. hypoglycemia -> even if it’s a normal value (if 
 - no treatments (except for enema’s)

they say it, it is it)
 - be cautious about allowing them to catheterize (if 

iv. pulselessness & breathlessness
 that’s the only option, pick that)
-> it’s lowest priority only at the scene of a 
 • Aids can do ADL’s (i.e. bed baths etc.) but
unwitnessed accident shouldn’t do the first of anything
• In extended care facilities, RPN’s can many of the LOCATIONS
things listed that they can’t do because in that setting, • point & click questions
the PT population is a generally stable one. • abdomen quadrants:

• DO NOT DELEGATE TO THE FAMILY SAFETY - i.e. what quadrant an organ is located etc.
RESPONSIBILITIES
 • locations for auscultating the heart valves:

- the nurse is responsible for that
 -> you have to know exact spots

- you cannot delegate safety to a non-hospital 
 - aortic = 2nd intercostal at R sternal border

caregiver
 - pulmonic = 2nd intercostal at L sternal border

-> you can to a sitter but they can only do what you 
 - tricuspid = 4th intercostal at L sternal border

teach them to do and document that you taught 
 - mitral = 5th intercostal at mid-clavicular line (where 

them (& their competency)
 the apical pulse is)
- ex. If a PT’s family member asks that you remove 
 • pulses: 

restraints while they are there because they are 
 - carotid - femoral - posterior tibial

watching them and that you can put them back on 
 - radial - popliteal - dorsalis pedis

once they leave -> NO - brachial

STAFF MANAGEMENT:
• How do you intervene w/ inappropriate behavior of
staff? (handling your staff when they do stupid things) TEST TAKING TIPS
• There are always 4 answers:
 • expect to do guessing on the test

*** the same answers show up all the time
 -> that’s the nature of computer adaptive testing
a) tell supervisor
 • How do you guess???

b) confront them and/or take over immediately
 a) use your knowledge first!

c) at a later date just talk to them
 b) common sense

c) a guessing strategy
d) ignore it —> NEVER the answer (you never ignore 

inappropriate behavior by staff)

- the first 3 could be right or wrong depending on the 
 GUESSING Strategies: (ONLY when you don’t know
situation so you need to learn how to choose 
 what’s going on; use knowledge & common sense first!)
between them • Psych Questions:

- the best answer (if you’re totally clueless) is “the 

• When you get a staff question ask yourself: 

a) first -> “Is what they are doing illegal?”
 nurse will examine their own feelings about…”

YES = always choose “tell supervisor”
 -> that way you don’t counter-transfer (ex. the PT 

NO = go to the next question
 reminds you of your dad & you didn’t like your 

b) “Is anyone (PT or staff) in immediate danger of 
 dad so you treat him badly)

physical or psychological harm?”
 - “establish a trust relationship”

YES = “confront immediately &/or take over” (so no 
 -> if you pick something else you’re saying it’s not 

one gets hurt; “telling supervisor” delays you 
 that important to establish trust

doing something putting others at risk) 
 -> BUT use common sense first! (ex. if a PT is 

NO = go to next question
 coming at you w/ a knife, safety first duh!)
c) “Is this behavior legal, not harmful, but simply 
 • Nutrition/Food Questions:

inappropriate?”
 - in a tie, pick chicken (obvs. not fried)

YES = “approach later”, no rush
 - if chicken is not there, pick fish

*** if a situation is both illegal & harmful you need to 
 -> not shellfish

confront/do something first & then call supervisor 
 - never pick casseroles for children (won’t eat it)

(because you don’t want to add more risk for harm 
 - never mix medication in children’s food

by delaying) BUT if it’s just illegal, tell supervisor -> if doing it for an adult, ask permission first

- toddlers = finger-food

-> might not be very healthy but they need stuff that 

they can eat on the run

- preschoolers = leave them alone (one meal a day 

is ok -> they eat when their hungry & usually picky)
• Pharmacology:

- the most common area tested is side effects

-> don’t memorize dosages! routes! frequencies!

-> FOCUS ON SIDE EFFECTS = we assess side 

effects, see if things are working (don’t prescribe)

 - if you know what a drug does but you don’t 
 • Sesame Street rule:

know the side effects:
 - you can use the rule when (& ONLY when) your only 

-> pick a side effect in the same body system where 
 remaining option is to give up -> WHEN NOTHING 

the drug is working
 ELSE WORKS

- if you have no clue what the drug is:
 - “ 3 of these things is not like the other”

-> see if it’s PO & if it is pick a GI side effect
 - the right answer tends to be different than the others

- never tell a child that medicine is candy -> because it is the only one which is correct

• OB Questions:
 -> usually the more unique & different option

- “check fetal heart rate” - the wrong answers are similar because they share 

• Med-Surge Questions:
 something in common

- first thing you assess = LOC (not airway)
 -> they are all wrong
-> before you do compressions you call out the PT’s 

name/try to wake them up which is LOC
 • don’t be tempted to answer a question based on
- first thing you do = establish an airway your ignorance instead of your knowledge:

• Pediatric Questions:
 - base answers on what you know, not what you don’t know

- growth & development questions are all based on 
 - if you don’t know something in a question, pull that 

the principle “always give the child more time” (to 
 out and focus on the things you do know

grow & develop, don’t rush it)
 - USE COMMON SENSE! boards test obscure things 

-> 3 Rules:
 to test your common sense
i. when in doubt, call it normal (in med-surge, 
 • if something really seems right, it probably is

when in doubt, call it abnormal so you don’t 
 - go w/ your gut!

make safety mistakes)
 -> unless you can prove that a different answer is 

ii. when in doubt, pick the older age (the older 
 superior (not “just as good”)
age of the 2 that it could be, not the oldest; gives 

more time)
 3 Expectations You’re NOT Allowed to Have:
iii. when in doubt, pick the easier task (gives 
 • expectations that are not met breed negativity which
more time for the child to learn it) badly affects your test taking
• a) don’t expect 75 questions

• General guessing skills:
 - prepare yourself for 250 questions

- rule out absolutes 
 - if you get to 200 it doesn’t mean you’re failing (it 

-> generally not good answers because they don’t 
 would have shut off earlier if you were)
apply to many situations
 • b) don’t expect to know everything

-> don’t forget your knowledge & common sense (i.e. 
 - because it’s computer adaptive -> it will give you 

certain things are absolute like “never push IV K+” 
 stuff you don’t know

or doing checks for med. administration)
 - know what everyone else needs to know
- if 2 answers say the same thing, neither is right 
 • c) don’t expect everything to go right

- if 2 answers are opposite, one of them is 
 - don’t expect a perfect day
probably right
 

- the umbrella strategy:
 

-> “which answer is more global”

* ex. certain questions where you want to say “all 

of the above” but that’s not an option -> look for 

an answer that is broad enough that covers all 

the things you need (covers all the other answers)

- if the question gives you 4 right answers & asks 

you to pick the one that is highest priority:

-> different from picking between 4 PT’s; usually the 

question is about 1 PT & you’re picking between 

4 different needs

-> think “worst consequences” for each option & 

pick the answer that has the worst outcome if you 

don’t pick it

- when you’re stuck between 2 answers, read the 

question (it will have the clue!!)