Live NCLEX Review Lecture Slides-2

Live NCLEX
Review
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Cait Capablanca: cait.capa@archerreview.com
Morgan Taylor: morgan@archerreview.com
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Part I -
Fundamentals
Lab Values
Need to know NCLEX
numbers!
Complete Blood Count (CBC)

● Hemoglobin (Hgb)
○ Female: 12-16 g/dL
○ Male: 14-18 g/dL
● Hematocrit (Hct)
○ Female: 37-47%
○ Male: 42-52%
● Red Blood Cells (RBCs)
○ 4.5-5.5 million
● White Blood Cells (WBCs)
○ 5,000 - 10,000
● Platelets
○ 150,000 - 400,000
Metabolic Panel
● Sodium - 135-145 ● Total protein - 6.4 - 8.3
● Potassium - 3.5 - 5 ● Albumin - 3.5 - 5
● Calcium - 9 -10.5 ● Bilirubin - <1
● Magnesium - 1.5 - 2.5 ● Ammonia - 15 - 110
● Chloride - 98 - 106 ● AST - 0 - 35
● Phosphorus - 2.5 - 4.5 ● ALT - 4 - 36
● Glucose 70-110 ● ALP - 30 - 120
● BUN - 10 - 20
● Creatinine - 0.6-1.2
● GFR - >90
Coagulation Panel
● Activated partial thromboplastin time (aPTT)
○ Tests the intrinsic coagulation cascade
○ Not on anticoagulants: 30 - 40 seconds
○ On Heparin, ‘therapeutic aPTT’ is 1.5-2.5x normal.
● Prothrombin Time (PT)
○ Tests the extrinsic coagulation cascade
○ 10 - 12 seconds
● International Normalized Ratio (INR)
○ It is calculated from a PT and is used to monitor how well warfarin is working.
○ Not on anticoagulants: 0.9-1.2
○ Taking warfarin, ‘therapeutic INR - 2-3
Cardiac Labs
● Troponin
○ Troponins are a group of proteins found in skeletal and cardiac muscle fibers that
regulate muscular contraction.
○ Test measures the level of cardiac-specific troponin in the blood to help detect heart
injury.
○ Several types of troponin
○ Normal = 0-0.4
● BNP
○ When there is fluid retention, the heart
senses the need to pump harder to move
fluid forward, and releases BNP.
○ Test for CHF
○ Normal <100
Lipid Panel
● Total cholesterol <200
● HDL > 55
● LDL < 130
● Triglycerides <160
Misc.
● HbA1C
○ Non-diabetic: 4-5.6%
○ Pre-diabetes: 5.7-6.4%
○ Diabetic - >6.5%
○ Target level for diabetics - <7%
● D-dimer
○ <500 ng/mL
● CRP
○ <1 mg/dL
ABG
Interpretation
Get it right, every time!
*TIP! click on any of the 'small group images', and this PDF will take you to the
booking page!*
Acid Base Balance
● The body likes the pH to be 7.35-7.45
● If it gets higher or lower than this, it tries to bring it back into normal range!
○ This is called COMPENSATION
● There are two ways to compensate
○ Metabolic
■ Kidneys make bicarbonate - a base
● More bicarb → more alkalotic (pH goes HIGHER)
● Less bicarb → more acidotic (pH goes LOWER)
○ Respiratory
■ Lungs either retain, or blow off, CO2
● More CO2 → more acidotic (pH goes LOWER)
● Less CO2 → → more alkalotic (pH goes HIGHER)
Normal Values
pH 7.35-7.45
Bicarbonate (HCO3) 22-28
CO2 35-45
Bicarb = BASE → metabolic

CO2 = ACID → respiratory
Step 1: Compensated or uncompensated?
UN
compensated!
NO!
No Compensated!
Is the pH normal??
7.35-7.45
Yes Normal!!
Are the CO2 and
YES!
HCO3 normal?
Step 2: Acidotic or alkalotic?
But… what if it’s compensated?!
If the pH is between 7.35 and 7.45, but you have determined that the gas is compensated, it is an
acidosis if the pH is <7.4 and an alkalosis if the pH is >7.4…. Essentially whatever side it is closest to!
Step 3: Metabolic or Respiratory?
CO2 HCO3
Respiratory acidosis: Respiratory alkalosis: Metabolic acidosis: Metabolic alkalosis:

-Hypoventilation -Hyperventilation -Loss of bicarb -Too much sodium bicarb
-Overdose -Panic attack -Diarrhea -Antacids
-COPD -Diuretics -Renal disease
-Asthma -Vomiting
Putting it all together

1. Compensated or uncompensated
2. Alkalosis or acidosis
3. Metabolic or respiratory
Let’s practice together!

Your client has the following arterial blood gas values:
pH 7.58
CO2 41
HCO3 38
pH 7.58
CO2 41
HCO3 38
1. Compensated or uncompensated?
○ The pH is in OUT of normal range- this is UNCOMPENSATED.
○ The pH is higher than 7.45 - this is ALKALOSIS.
○ There is a high amount of HCO3, a base, correlating with our alkalosis - this is METABOLIC.
UNCOMPENSATED METABOLIC ALKALOSIS

ABG Worksheet
Your client has the following arterial blood gas values:
pH 7.36
CO2 69
HCO3 37
pH 7.36
CO2 69
HCO3 37
1. Compensated or uncompensated?
○ The pH is in normal range, but the CO2 and HCO3 are not - this is COMPENSATED.
○ The pH is normal - but closer to 7.35 - this is ACIDOSIS.
○ There is a high amount of CO2, an acid, correlating with our acidosis - this is RESPIRATORY.
COMPENSATED RESPIRATORY ACIDOSIS

Fluids and
Electrolytes
*TIP! If you're viewing these notes in a PDF, all of these short videos videos that play during the live review are
linked right here! Just click on them and a window will open to play the video clip.*
Sodium - Na+
● The most abundant extracellular cation
● Regulates water in the cells of the body
● Water follows sodium
● Sodium is important in:
○ The brain
○ Nerves
○ Muscle cells
● Normal sodium: 135 - 145 mEq/L
Hyponatremia
Fluids and electrolytes
Hypervolemic & Euvolemic hyponatremia
Euvolemic Hypervolemic
Water in the body increases, but the sodium level Water in the body increases to point of
stays the same. The client remains in a euvolemic hypervolemia, which dilutes the amount of sodium
state where their fluid balance is normal. in the serum causing a ‘dilutional’ or ‘relative’
hyponatremia.
Causes:
Causes:
● SIADH
● Adrenal insufficiency ● CHF
● Addison’s disease ● Kidney failure
● Polydipsia ● Nephrotic syndrome
● Excessive hypotonic IVF ● Liver failure
● Low dietary intake of sodium ● Water intoxication
Hypovolemic hyponatremia
Water and sodium are both lost.
Causes:
● Vomiting
● Diarrhea
● NG suction
● Diuretics
● Burns
● Excessive sweating
Assessment
Neuro Musculoskeletal CV
● Seizures ● Abdominal cramps ● Hypovolemia

Weakness ○ Weak pulse
● Confusion ●
○ Tachycardia
● Lethargy ● Shallow respirations
○ Hypotension
● Stupor ● Decreased deep tendon reflexes ○ Dizziness
● Cerebral edema ● Muscle spasms ● Hypervolemia
● Increased ICP ● Orthostatic hypotension ○ Bounding pulses
○ Hypertension
GI/GU
● Loss of appetite
● Hyperactive bowel sounds
Treatment
Hypovolemic hyponatremia Hypervolemic/Euvolemic
hyponatremia
● Must restore volume AND
sodium ● Restrict free water
● Mild - 0.9% NS (isotonic) ● Sodium tablets
● Severe - 3% NS (hypertonic) ● Osmotic diuretics
● Encourage high salt foods
Nursing interventions
● Encourage increased oral sodium intake
○ Bacon
○ Butter
○ Canned food
○ Cheese
○ Hot dogs
○ Lunch meat
○ Processed food
○ Table salt
● Sometimes sodium tablets prescribed
● Monitor neuro status!
Replacing sodium
● Replace sodium slowly
● 0.5 mEq/hr
● Changing the sodium level too quickly causes fluid shifts
○ Cerebral edema
○ Increased ICP
Hypernatremia
Causes
Euvolemic hypernatremia Hypervolemic hypernatremia Hypovolemic hypernatremia
Decreased water with near Increased sodium AND water… but Decreased water AND sodium...but
normal sodium. MORE sodium! MORE water loss!
● Increased insensible ● Hypertonic IVF ● Dehydration

● Sodium bicarbonate NPO
water loss ●
● Increased sodium intake ● Diarrhea
○ Hyperventilation
○ Excessive sweating ● Corticosteroids ● Vomiting
○ Fever ● Cushing’s ● Burns
● Diabetes insipidus ● Hyperaldosteronism ● Diuretics
The loss of fluids leads to a relative

increase in the amount of Na+ in the
blood.
Assessment
Neuro Musculoskeletal CV Other
● Restless ● Twitching ● Fever ● Flushed skin

● Agitated ● Cramps ● Hypervolemic ● Decreased UOP
● Lethargic ● Weakness ○ Edema ● Dry mouth
● Drowsy ○ Hypertension
● Stupor ○ Bounding pulses
● Coma ● Hypovolemic
○ Hypotension
○ Weak pulses
Treatment
Euvolemic hypernatremia Hypervolemic hypernatremia Hypovolemic hypernatremia
● Free water administration ● Find the causative agent ● Isotonic fluid administration
○ Based on the free and discontinue ○ NS is “relatively
water deficit ○ 3% administration? hypotonic” to the body in
● PO intake better than IV ○ Aldosterone excess? hypernatremia.
because client is ● Loop diuretics
euvolemic ● Free water administration
Monitor neuro status

Correct imbalance SLOWLY - Risk for cerebral edema
NCLEX Question
The nurse is caring for a client whose most recent serum sodium level was 152 mEq/L.
Which of the following signs and symptoms dos they suspect are caused by the client's
sodium level? Select all that apply.
a. Lethargy
b. Dry mucous membranes
c. Tachypnea
d. Cyanosis
e. Dry mouth
Answer: A, B, and E
A is correct. Sodium plays a very important role in the brain, and imbalances in the serum sodium level can cause major
neurological changes. The client who is hypernatremic, or has a sodium level greater than 145 mEq/L is at risk for changes
in their level of consciousness ranging from restlessness and agitation to lethargy, stupor, and coma.
B is correct. The client who has a high sodium level, greater than 145 mEq/L will have dry mucous membranes. This is
due to the relationship sodium has with water. Water follows sodium, so where there is an increased level of sodium in
the extracellular space, water leaves the cells and follows the sodium into the extracellular space. This causes the dry
mouth and mucous membranes.
C is incorrect. Tachypnea, or an increased respiratory rate, is not a symptom of hypernatremia. Sodium plays a very
important role in the brain and nerves as well as water balance. The major symptoms to monitor for will be neurological,
not respiratory.
D is incorrect. Cyanosis, or a bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of
the blood, is not a symptom of hypernatremia. Sodium imbalance can cause many devastating neurological symptoms, but
will not result in cyanosis.
E is correct. Dry mucous membranes are an expected finding in hypernatremia.

NCSBN Client Need:
Topic: Physiological Integrity Subtopic: Risk potential reduction
Reference: Cooper, K., & Gosnell, K. (2019). Study Guide for Foundations and Adult Health Nursing-E-Book. Elsevier Health Sciences.
Subject: Fundamentals of care

Lesson: Fluids & Electrolytes
Potassium - K
● Found mostly inside the cells - most abundant intracellular cation.
● Normal value is for serum level - the potassium in the blood, outside of the cells.
● Responsible for nerve impulse conduction
● Important in muscle contraction - heart muscle and skeletal muscle.
● Important in acid-base balance
○ Acidotic → increased K+
● Normal potassium: 3.5 - 5.0
Hyperkalemia
Causes
● Too much potassium moved from intracellular to extracellular
○ Burns
○ Tissue damage
○ Diabetic ketoacidosis
● Too much total potassium
○ Renal failure
○ Excessive K+ intake
● Medications
○ ACE inhibitors
○ Potassium-sparing diuretics
Assessment
● Muscle weakness
● Numbness
● Shallow respirations → respiratory failure
● Cramping
● Hyperactive bowel sounds
● Diarrhea
● Impaired contractility → decreased CO
○ Weak pulses
○ Bradycardia
○ Hypotension
● EKG CHANGES
EKG Changes
● Wide, flat P waves

● Prolonged PR interval
● Widened QRS interval
● Depressed ST segment
● Tall, peaked T waves
Can lead to heart block, or V-fib….eventually cardiac arrest!
Treatment
Interventions depend on severity of hyperkalemia and the symptoms present
● MONITOR CARDIAC RHYTHM ● Drive potassium into cells
● Discontinue any potassium ○ D5W + regular insulin
○ Albuterol
supplements
○ Bicarbonate
○ IV potassium
○ PO supplements
● Reduce total body potassium
○ Kayexalate
● Potassium restricted diet
○ Diuretics
● IV Calcium gluconate or chloride ■ Hydrochlorothiazide
○ Given if EKG changes are present to ■ Lasix
protect the myocardium ● Dialysis
○ Used when severe hyperkalemia is
not responding to other
interventions
High potassium foods
Hypokalemia
Causes - DITCH
Drugs Too much water Heavy fluid loss
- Laxatives - Polydipsia - NGT suction
- Diuretics - Excessive IVF - Vomiting
- Corticosteroids administration - Diarrhea
- Wound drainage
Inadequate K intake Cushing’s Syndrome - Sweating
- NPO - Too much cortisol
- Poor diet - Retention of Na/Water Other
- Anorexia nervosa - Secretion of K - Alkalosis
- Bulimia nervosa - Hyperinsulinism
- Alcoholism
Assessment
● Decreased deep tendon reflexes
● Weakness
● Flaccidity
● Shallow respirations
● Decreased bowel sounds
● Constipation
● Abdominal distention
● Orthostatic hypotension
● Weak, thready pulse
● Cardiac dysrhythmias
EKG Changes
● Slightly peaked P wave

● Slightly prolonged PR interval
● ST depression
● Flat/shallow/inverted T waves
● Prominent u-waves
Treatment
● Place on cardiac telemetry
● Hold lasix or other potassium wasting drugs
● Hold digoxin
● Diet rich in potassium
● Oral potassium supplements
○ Give with food to prevent GI upset
● IV potassium supplements
IV potassium supplement administration
● NEVER GIVE IV PUSH
● Give according to instructions; SLOWLY
● Monitor IV site very carefully
○ Can cause phlebitis
○ If extravasation occurs will cause tissue damage
NCLEX Question
The nurse is evaluating their client's lab results and notes that the potassium is 5.5
mEq/L. They review the telemetry monitor, looking for which of the following signs?
Select all that apply.
a. Inverted T waves
b. Widened QRS interval
c. Tall, peaked T waves
d. Prominent U-waves
e. Prolonged PR interval
Test Taking Tool
The nurse is evaluating their client's lab results and notes that the potassium is 5.5
mEq/L. They review the telemetry monitor, looking for which of the following signs?
a. Inverted T waves
b. Widened QRS interval
c. Tall, peaked T waves
d. Prominent U-waves
e. Prolonged PR interval
Answer: B, C, and E
A is incorrect. The normal range for potassium is 3.5 - 5 mEq/L. This client is experiencing hyperkalemia. In
hyperkalemia, there are Tall, peaked T waves. Inverted T waves is a sign of hypokalemia.
B is correct. A widened QRS interval is a very important EKG finding in hyperkalemia. Other EKG changes clients
may experience when they are hyperkalemic include wide, flat P waves, a prolonged PR interval, a depressed ST
segment, and tall, peaked T waves.
C is correct. Tall, peaked T waves is a hallmark sign of hyperkalemia on an EKG. Remember this one - it is a very
common topic for NCLEX questions!! Hyperkalemia leads to serious arrhythmias, and can progress to heart block,
ventricular fibrillation, or even asystole if left untreated.
D is incorrect. The normal range for potassium is 3.5 - 5 mEq/L. This client is experiencing hyperkalemia.
Prominent U-waves are a sign of hypokalemia, or a potassium less than 3.5, not hyperkalemia.
E is correct. A prolonged PR interval is one of the EKG changes that occurs with hyperkalemia.
NCSBN Client Need:

Calcium - Ca
● Stored in the bones, absorbed in the GI system, and excreted by the kidneys
● Plays an important role in bones, teeth, neves, and muscles
● Important for coagulation
● Is controlled by PTH and Vitamin D
● Has an inverse relationship with Phosphorus
● Normal calcium: 8.4 - 10.2
Hypercalcemia
Causes
● Excessive intake of calcium
● Hyperparathyroidism
● Excessive intake of Vitamin D
● Vitamin D toxicity
● Cancer of the bones

● Immobility
● Glucocorticoids
Assessment
Neuromuscular Cardiovascular Gastrointestinal Neuro
● Weakness ● Bradycardia ● Decreased ● Fatigue

● Flaccidity ● Cyanosis peristalsis ● Decreased
● Decreased deep ● Deep vein ● Hypoactive LOC
tendon reflexes thrombosis bowel sounds
● Abdominal pain
● Nausea
● Vomiting
● Constipation
● Kidney stones
Treatment
● Reduce dietary intake of calcium
● Encourage PO hydration
● IV fluids - NS preferred
● Loop diuretics
● Calcium binders
● Dialysis
● Cardiac monitoring
Hypocalcemia
Causes
● Renal failure
● Acute pancreatitis
● Malnutrition
● Malabsorption
○ Celiac disease
○ Crohn’s disease
● Alcoholism
● Bulimia
● Vitamin D deficiency
● Hypoparathyroidism
● Hyperphosphatemia
Assessment
Neuromuscular Gastrointestinal Misc.
● Irritability ● Hyperactive ● Weak bones

● Hallucinations bowel sounds ○ Increased risk of fractures
● Paresthesias ● Cramping ● Weak/brittle nails

● Tetany ● Diarrhea
● Seizures
● Muscle spasms
● Chvostek’s sign
● Trousseau’s sign
Treatment
● PO calcium supplements
○ Administer with Vitamin D
○ Increases absorption
● IV calcium supplements
● Calcium rich diet
NCLEX Question
The nurse is reviewing their clients laboratory findings and notes that one of her clients has a
serum calcium level of 7.2 mg/dL. They know that of each of the following clients, which ones are
most likely to have this result? Select all that apply.
a. The client with breast cancer and bone metastases

b. The client with obesity
c. The client with Vitamin D toxicity
d. The client with hypoparathyroidism
e. client with chronic renal failure
Answer: D and E
A is incorrect. The client with malignancy and bone metastases are more likely to have hypercalcemia, not hypocalcemia. This is due to
bone destruction from osteoclasts and the leak of calcium into blood. In addition, malignancies often cause "paraneoplastic hypercalcemia"
by secreting substances called "PTH-related peptides" that have actions similar to Parathormone ( PTH).
B is incorrect. Obesity is not a risk factor for hypocalcemia. Malnutrition and malabsorption, such as in celiac and crohn’s disease clients, can
cause hypocalcemia due to decreased absorption, but obesity would not cause this.
C is incorrect. The client with Vitamin D toxicity would put a client at risk for hypercalcemia, or a serum calcium level greater than 10.2
mg/dL. This is due to the relationship between Vitamin D and calcium; Vitamin D enhances the absorption of calcium. Therefore, Vitamin D
toxicity would lead to increased absorption of calcium and a hypercalcemic state.
D is correct. The client with hypoparathyroidism is most likely to suffer from hypocalcemia. The normal calcium level is 8.4-10.2 mg/dL, so
with this client's level of 7.2 they have too little calcium in the blood. The client who experiences hypoparathyroidism has too little
parathyroid hormone (PTH). PTH regulates the serum calcium concentration through its effects on the bones, kidneys, and intestines. When
there is too little PTH, there are decreased calcium levels, or hypocalcemia.
E is correct. Hypocalcemia is a common problem in chronic renal failure and end-stage renal disease (ESRD). There are two reasons for
hypocalcemia in kidney disease: increased phosphorus and decreased renal production of activated Vitamin D (1,25 Dihydroxy vitamin D).
Phosphorus accumulates in renal failure. Hyperphosphatemia results in binding to calcium and precipitates as calcium phosphate in tissues
and bones, causing hypocalcemia. The kidney is responsible for activating Vitamin D and restoring calcium balance. In the setting of renal
diseases, one loses the capacity to activate vitamin D and calcium level drops. For these reasons, physicians often order phosphate binders
to reduce phosphorus and calcitriol (activated vitamin D, 1,25 Dihydroxy vitamin D) in chronic renal failure/ ESRD.
Break Back at….
Magnesium - Mg
● Stored in the bones and cartilage
● Plays a major role in skeletal muscle contraction
● Important for ATP formation
● Activates vitamins
● Necessary for cellular growth
● Is directly related to calcium
● Normal magnesium: 1.6-2.6 mg/dL

Hypermagnesemia
Fluids and Electrolytes
Causes
● Excessive dietary intake
● Too many magnesium containing medications
● Over-correction of hypomagnesemia
● Renal failure
Assessment
Neuromuscular Cardiovascular Neuro
● Weakness ● Bradycardia ● Drowsy

● Shallow breathing ● Hypotension ● Lethargy
● Slowed reflexes ● Vasodilation ● Coma
● Decreased deep ○ Flutheyd
○ Feel warm
tendon reflexes
Treatment
● Treat the cause
● Hold any fluids or meds containing Mag
● Loop diuretics
● Calcium gluconate
● Dialysis
Hypomagnesemia
Causes
● Alcoholism
● Malnutrition
● Malabsorption
● Hypoparathyroidism
● Hypocalcemia
● Diarrhea
Assessment
Neuromuscular Neuro Gastrointestinal
● Numbness ● Psychosis ● Nausea

● Tingling ● Confusion ● Vomiting
● Cramping ● Abdominal cramps
● Tetany CV ● Anorexia
● Seizures ● Torsades de pointes
● Increased deep
tendon reflexes
EKG Changes - Torsade de Pointes

Treatment
● Treat the cause
● Monitor cardiac rhythm
● Administer magnesium
○ PO - Magnesium hydroxide
○ IV - given very slowly
NCLEX Question
The nurse is caring for a client with a serum magnesium level of 3.2 mg/dL.
they know that which of the following could have caused this electrolyte
abnormality? Select all that apply.
a. Renal failure
b. Alcoholism
c. Anorexia
d. Diarrhea
e. Malnutrition
NCLEX Question
The nurse is caring for a client with a serum magnesium level of 3.2 mg/dL.
they know that which of the following could have caused this electrolyte
abnormality? Select all that apply.
a. Renal failure
b. Alcoholism
c. Anorexia
d. Diarrhea
e. Malnutrition
Answer: A
A is correct. The normal magnesium level is 1.6-2.6 mg/dL. This client has a level of 3.2, and is experiencing
hypermagnesemia. Renal failure can cause hypermagnesemia due to the fact that the process that keeps the levels of
magnesium in the body at normal levels does not work properly in people with kidney dysfunction.
B is incorrect. Alcoholism is a risk factor for hypomagnesemia, and this client has hypermagnesemia. Hypomagnesemia is
the most common electrolyte abnormality observed in alcoholic clients. There is a loss of magnesium from tissues and
increased urinary loss, and chronic alcohol abuse depletes the total body supply of magnesium.
C is incorrect. Anorexia is a risk factor for hypomagnesemia, and this client has hypermagnesemia. This is due to
malnutrition and a lack of dietary intake of magnesium.
D is incorrect. Diarrhea is a risk factor for hypomagnesemia, and this client has hypermagnesemia. Magnesium is
absorbed in the GI tract, and with diarrhea there is decreased absorption of magnesium leading to hypomagnesemia.
E is incorrect. A patient who is malnourished will have had a poor dietary intake of magnesium, leading to
hypomagnesemia.
NCSBN Client Need:

Phosphorus
● Major role is in cellular metabolism and energy production (ATP)
● Makes up the phospholipid bilayer of cell membranes
● Large component of bones and teeth
● Has an inverse relationship with Calcium
● Normal phosphorus: 3.0-4.5 mg/dL
Hyperphosphatemia

Causes
● Excessive dietary intake of phosphorus
● Tumor lysis syndrome
● Renal failure
● Hypoparathyroidism → Hypocalcemia → Hyperphosphatemia
Assessment
Symptoms are related to the hypocalcemia secondary to hyperphosphatemia.
Treatment
● Phosphate binders
○ Given with food
● Manage hypocalcemia
Hypophosphatemia
Causes
● Malnutrition
● Alcoholism
● TPN
● Hyperparathyroidism → hypercalcemia → hypophosphatemia
Assessment
Symptoms are related to the hypercalcemia secondary to hypophosphatemia.
Treatment
● Treat the cause
● Phosphorus replacement
○ PO
○ IV - given slowly
● Phosphorus rich diet
● Diet low in calcium
NCLEX Question
The nurse is caring for a client with a phosphorus level of 5.0 mg/dL. they knows that
which of the following are possible causes of this condition? Select all that apply.
a. Tumor lysis syndrome

b. Hypoparathyroidism
c. Hypercalcemia
d. Renal failure
e. Superior Vena Cava syndrome
NCLEX Question
The nurse is caring for a client with a phosphorus level of 5.0 mg/dL. they knows that
which of the following are possible causes of this condition? Select all that apply.
a. Tumor lysis syndrome

b. Hypoparathyroidism
c. Hypercalcemia
d. Renal failure
e. Superior Vena Cava syndrome
Answer: A, B, and D
A is correct. This client has a phosphorus level of 5.0, which is greater than the normal 3.0-4.5 mg/dL. Tumor lysis
syndrome can cause increased phosphorus levels, because when a tumor lyses the cellular contents (including
phosphorus) are spilled out into the blood causing an increase in their serum levels .
B is correct. Hypoparathyroidism is a cause of hyperphosphatemia. The client who experiences hypoparathyroidism has
too little parathyroid hormone (PTH). PTH regulates the serum calcium concentration through its effects on the bones,
kidneys, and intestines. When there is too little PTH, there are decreased calcium levels, or hypocalcemia. Because calcium
and phosphorus have an inverse relationship, when there are low levels of calcium there are high levels of phosphorus.
Thus, hypoparathyroidism causes hyperphosphatemia.
C is incorrect. Hypercalcemia is a cause of hypophosphatemia. This client has a phosphorus level of 5.0, which is greater
than the normal 3.0-4.5 mg/dL, not less than. Phosphorus and calcium have an inverse relationship, when there are high
levels of calcium there are low levels of phosphorus. Thus, hypercalcemia would cause hypophosphatemia.
D is correct. Renal failure is a cause of hyperphosphatemia. Due to reduced kidney function, phosphorus is not able to be
excreted as readily as it normally would and increased levels of phosphorus build up in the blood causing
hyperphosphatemia.
E is incorrect. Superior Vena Cava syndrome is another oncologic emergency, but it has no impact on the patients
phosphorus levels.
Chloride - Cl
● Most abundant extracellular anion
● Works with sodium to maintain fluid balance
● Binds with hydrogen ions to form stomach acid - HCl
● Inversely related to bicarbonate
● Directly related to sodium and potassium
● Normal chloride: 96-108 mEq/L

Hyperchloremia
Causes
● Fluid loss
○ Dehydration
○ Vomiting
○ Sweating
● Steroids
○ Cushing’s disease
○ Excess corticosteroid administration
● Excess chloride administration
○ NORMAL SALINE!
Assessment
● Signs and symptoms of hypernatremia
Treatment
● Treat the underlying cause
● Correct the imbalance
○ Bicarbonate administration
○ Discontinue any sodium containing meds
○ No NS for IVFs - consider LR instead
● Monitor all electrolytes - it’s usually not the only imbalance!
Hypochloremia
Causes
● Volume overload
○ CHF
○ Water intoxication
● Salt losses:
○ Burns
○ Sweating
○ Vomiting
○ Diarrhea
○ Cystic Fibrosis
○ Addison’s Disease
Assessment
● Signs and symptoms of hyponatremia
Treatment
● Treat the underlying cause
● Correct the imbalance
○ Normal Saline - 0.9% NaCL
● Monitor all electrolytes - it’s usually not the only imbalance!
NCLEX Question
The nurse is caring for a client who has a chloride level of 115 mEq/L. Which of the
following maintenance IV fluids do they anticipate the provider will order?
a. 3% NS
b. Normal Saline IVF
c. Lactated Ringers IVF
d. D5NS
NCLEX Question
The nurse is caring for a client who has a chloride level of 115 mEq/L. Which of the
following maintenance IV fluids do they anticipate the provider will order?
a. 3% NS
b. Normal Saline IVF
c. Lactated Ringers IVF
d. D5NS
Answer: C
A is incorrect. 3% NS contains chloride, as it is 3% sodium chloride. This is a hypertonic fluid, most often used to lower
ICP in the setting of cerebral edema. It should not be administered to the patient with hyperchloremia.
B is incorrect. Normal Saline, or 0.9% NaCl, contains chloride. As the name suggests - NaCl, or Sodium Chloride. If the
client has a chloride level of 115 mEq/L, they have hyperchloremia, as their chloride level is above the normal range of
96-108 mEq/L. It would therefore not be appropriate for the nurse to prepare to administer normal saline to this client.
C is correct. Lactated Ringers IVF is the appropriate choice for IV fluids for the client with hyperchloremia. Normal Saline
should be avoided as to prevent increasing the chloride level further. Hydration is a very important component in treating
hyperchloremia, so providing IVF for hydration is appropriate, it just needs to be the correct fluid.
D is incorrect. D5NS, or Dextrose 5% in normal saline, also contains chloride and is therefore inappropriate in your patient
with hyperchloremia.
NCSBN Client Need:


Fluids
Fluid Volume Excess
Causes
● Excessive fluid intake
● PO intake
● IV fluid administration
● Excessive sodium intake
● Kidney failure
● Congestive heart failure
● Liver failure
Assessment
● High blood pressure
● Jugular venous distention
● Edema
● Weight gain
● Crackles
● Shortness of breath
Nursing Interventions
● Monitor I&O’s
● Daily weight
● Diuretics
● Hypotonic IVF
● Dialysis
Fluids
Fluid Volume Deficit
Causes
● Losing fluid
○ Trauma
○ Diarrhea
○ Vomiting
○ Sweating
○ Polyuria
■ DKA
● Not taking in sufficient fluid
○ Dehydration
○ Severe fluid restriction
Assessment
● Low blood pressure
● Tachycardia
● Weak pulses
● Concentrated urine
○ High specific gravity
○ High urine osmolality
● Thirsty
● Urine specific gravity: 1.005 to 1.030.

○ Measures the concentration of solutes in the urine. High specific gravity means high
solutes.
● Urine osmolality: 100-900.
○ Used to measure the number of dissolved particles per unit of water in the urine.
● Strict I&O’s
● Monitor BP and HR
● Daily weight
● IV fluids
IV Fluids
Must know types and
uses!
Isotonic IV Fluids
IV fluid with osmolarity similar to blood. Does NOT cause a shift in fluid.
● 0.9% Sodium Chloride (Normal Saline)

● Lactated Ringers (LR)
● D5W
Uses
● Increase the intravascular volume
● Blood loss
● Surgery
● Isotonic dehydration
● Fluid loss
● Maintenance fluids
● Patients who are NPO
Hypotonic IV Fluids
IV fluid with osmolarity lower than blood. Moves fluid out of blood vessels into
cells and interstitial spaces.
● 0.45% Sodium Chloride (½ Normal Saline)

● 0.33% or 0.2% Sodium Chloride
● 2.5% Dextrose in Water (D2.5W)
Uses
● DKA
● HHNS
● Hypernatremia
Hypertonic IV Fluids
IV fluid with osmolarity higher than blood. Moves fluid out of cells and interstitial
spaces and into blood vessels.
● 1.5%, 3%, or 5% Sodium Chloride

● D5NS
● D5LR
● D10W
Uses
● Hyponatremia
● Cerebral edema
Break Back at….
Pharmacology
Must know meds for
NCLEX success!
Anticoagulants
● Heparin
● Clopidogrel (Plavix)
● Warfarin
● Low-molecular weight heparin
Heparin
● Classification: Indirect Thrombin Inhibitor
○ Anticoagulant!
● How it works
○ Thrombin → converts fibrinogen to fibrin → Fibrin forms clots!
○ Antithrombin III inhibits Thrombin
○ Heparin ENHANCES antithrombin III
○ This stops thrombin from being activated, which therefore prevents clots from forming.
● This is the intrinsic coagulation pathway
End result? SLOWS DOWN CLOTTING.

Basic Information
● Uses
○ To prevent blood clots
■ Strokes
■ Chronic a-fib
■ Post-operatively
● Titration
○ Patients on a heparin drip have aPTT levels drawn q4-6 hours to titrate the drip.
■ Normal aPTT: 30-40 seconds
■ Therapeutic aPTT: 1.5-2x normal
Important Nursing Considerations

● Biggest side effect to monitor for = bleeding!
○ Hematuria - Pink tinged urine
○ Hematemesis - bloody vomitus
○ Bruising
○ Downtrending H&H
● Antidote = protamine sulfate
Heparin Induced Thrombocytopenia and Thrombosis (HITT)
● Complication of Heparin therapy
● Usually occurs 5-10 days after Heparin exposure
● Suspect in any client on Heparin who has an unexplained platelet drop
● Clinical manifestations:
○ Skin lesions at heparin injection sites
○ Chills
○ Fever
○ Dyspnea
○ Chest pain
● Complications - clotting!
○ DVT
○ PE
● Treatment
○ Discontinue ALL heparin and start a different anticoagulant!
Warfarin
Therapeutic class: Anticoagulant
Indication: venous thrombosis, pulmonary embolism, A-fib
Action: disrupts liver synthesis of Vitamin K dependent clotting factors
Nursing Considerations:
● Monitor for bleeding

● Monitor PT and INR
○ PT
■ Normal: 10-12 seconds
○ INR
■ Normal: 0.9-1.2
■ Therapeutic INR: 2-3
● Antidote: Vitamin K
● Contraindicated during pregnancy
NCLEX Question
The nurse is caring for a pregnant client who is at 16 weeks gestation. they
developed a pulmonary embolism and were initiated on heparin therapy two
days ago. They are getting ready to be discharged. Which of the following
medications do you expect the healthcare provider to order at discharge?
A. Warfarin
B. Rivaroxaban
C. Apixaban
D. Low Molecular Weight Heparin (LMWH)
Test Taking Tool

The nurse is caring for a pregnant client who is at 16 weeks gestation. they
developed a pulmonary embolism and were initiated on heparin therapy two
days ago. They are getting ready to be discharged. Which of the following
medications do you expect the healthcare provider to order at discharge?
A. Warfarin
B. Rivaroxaban
C. Apixaban
D. Low Molecular Weight Heparin (LMWH)
Answer: D
A is incorrect. Warfarin is contraindicated during pregnancy. It can cause
congenital disabilities, maternal bleeding, stillbirths, and miscarriages.
B and C are incorrect. Rivaroxaban and Apixaban belong to the class of Factor Xa
inhibitors. These are newer anticoagulants and are not safe in pregnancy.
D is correct. Low Molecular Weight Heparin is the drug of choice for

anticoagulation in pregnancy. It does not cross the placenta and therefore does
not cause fetal harm.
Anticonvulsants
● Phenytoin (Dilantin)
● Gabapentin
● Levetiracetam
Phenytoin
Therapeutic class: Anticonvulsant
Indication: Seizures
Action: blocks sustained high frequency repetitive firing of action potentials
● Therapeutic level: 10-20 mcg/mL

● Side effect: gingival hyperplasia
○ Regular dental check-ups
○ Use soft bristle toothbrush
● Antacids can reduce the effect of phenytoin and should be avoided.
Antianxiety Agents - Benzodiazepines

Short acting
● Midazolam | onset: rapid | duration 1-2 hours - quick on/ quick off
Intermediate acting
● Alprazolam | onset: intermediate | duration: 6-12 hours

● Clonazepam | onset: intermediate | duration: 18-50 hours
● Lorazepam | onset: rapid IV, intermediate PO| duration: 2-6 hours - medium on/long off
Long acting
● Diazepam| onset: rapid | duration: 20-50 hours - quick on/ long off
Lorazepam
Therapeutic class: antianxiety agent
Indication: anxiety, sedation, seizures
Action: general CNS depression
● Avoid alcohol
● Monitor for respiratory depression
● Antidote - flumazenil
Antidepressants
● SSRIs
○ Fluoxetine
○ Sertraline
○ Escitalopram
● TCAs
○ Amitriptyline
○ Nortriptyline
○ Protriptyline
● MAOIs
○ Isocarboxazid
○ Phenelzine
Selective Serotonin Reuptake Inhibitors - SSRIs
Examples: Fluoxetine, Sertraline, Escitalopram
Indication: Depression
Action: Prevent reuptake of serotonin increasing the availability of serotonin in

the body.
● Monitor for serotonin syndrome

○ Hypertension, confusion, anxiety, tremors, ataxia, sweating.
● Suicide precautions important for 2-3 weeks
○ When the client's mood starts to improve, they are are an inreased risk for suicide
○ Why? They now have the energy to follow through with a plan.
Tricyclic Antidepressants - TCA’s

Examples: Amitriptyline, Nortriptyline, Protriptyline
Action: Prevents the reuptake of norepinephrine and serotonin increasing these

neurotransmitters in the body..
● Monitor for anticholinergic side effects

○ Dry mouth, constipation, urinary retention
Monoamine Oxidase Inhibitors - MAOIs
Examples: isocarboxazid, phenelzine
Action: blocks monoamine oxidase enzymes to increase the levels of ALL

neurotransmitters ( dopamine, norepinephrine, epinephrine, serotonin)
● Avoid foods that are high in tyramine.

○ Aged cheeses
○ Wine
○ Pickled meats
● Side effect - hypertensive crisis
Mood Stabilizers
● Lithium
Lithium
Indication: Mania
Action: Inhibits excitatory neurotransmitters such as dopamine and glutamate,

and promotes GABA-mediated neurotransmission.
● Do not administer with NSAIDS

● Monitor drug levels:
○ Therapeutic level - 0.6-1.2 mEq/L
● Encourage adequate fluid intake
● Side effects:
○ Seizures, arrhythmias, fatigue, confusion, nausea, anorexia, hypothyroidism, tremors
Antipsychotics
● Haloperidol
● Quetiapine
● Olanzapine
Haloperidol
Therapeutic class: Antipsychotic
Indication: Schizophrenia, mania, aggressive behavior, agitation
Action: Inhibits the effects of dopamine
● Monitor for extrapyramidal side effects

● Tardive dyskinesia
● Neuroleptic malignant syndrome
● Can prolong the QT interval
○ Weekly EKG
● Contraindicated in pregnancy
Antihistamines
● Histamine-1 blocker → block H1 receptors in CNS - stopy allergies!
○ Diphenhydramine
● Histamine-2 blocker → block production of stomach acid!

○ Famotidine
○ Ranitidine
Diphenhydramine
Therapeutic class: Antihistamine
Indication: Allergy, anaphylaxis, sedation
Action: Antagonizes effects of histamine, CNS depression
● Monitor for drowsiness

● Anticholinergic effects
Diuretics
● Loop diuretics
○ Bumetanide
○ Furosemide
○ Torsemide
● Potassium sparing diuretics
○ Eplerenone
○ Spironolactone
● Thiazide diuretics
○ Chlorothiazide
○ Hydrochlorothiazide
Loop Diuretics
● Examples:
○ Bumetanide, Furosemide, Torsemide
● Mechanism of action:
○ Act on the loop of Henle to increase urine output by affecting sodium reabsorption within the
nephron.
○ Inhibits the sodium potassium chloride cotransporter causing sodium to be excreted in the
urine therefore increasing diuresis.
● Uses:
○ Increase urinary output, edema, CHF, blood pressure management.
● Nursing considerations:
○ Monitor potassium levels
● These are the most effective of all diuretics.
Potassium Sparing Diuretics

● Examples:
○ Spironolactone, Eplerenone
○ Inhibit sodium and potassium exchange via sodium channels in the distal parts of the
nephron.
○ This ‘spares’ potassium!!
● Uses:
○ Hypertension, edema, swelling, hypokalemia.
● Nursing considerations:
○ Monitor potassium levels
● These medications are not as strong as other diuretics, so are often
combined with a loop or thiazide diuretic!
Thiazide Diuretics
● Examples: Chlorothiazide, Hydrochlorothiazide
○ These diuretics act on the distal convoluted tubule to inhibit the sodium-chloride
cotransporter.
○ This increases sodium in the filtrate causing an increased amount of water reabsorption and
therefore increased urinary output.
● Uses:
○ Hypertension, CHF
● Nursing Considerations:
○ Monitor electrolyte levels
○ Monitor BP
Antihypertensives
● ACE inhibitors
○ Captopril
○ Enalapril
○ Lisinopril
● Angiotensin II Receptor Blockers
○ Losartan
● Calcium Channel Blockers
○ Amlodipine
○ Nifedipine
○ Verapamil
● Direct acting vasodilators
○ Hydralazine
○ Nitroglycerin
Enalapril
Therapeutic class: ACE inhibitor
Indication: Hypertension, CHF
Action: Blocks conversion of angiotensin I to angiotensin II, increases renin levels

and decreases aldosterone leading to vasodilation
● Can cause a dry cough - should be discontinued if it does.

● Monitor BP
Losartan
Therapeutic class: Angiotensin II receptor blocker (ARB)
Indication: hypertension, DM neuropathy, CHF
Action: inhibits vasoconstrictive properties of angiotensin II
● Monitor BP
● Monitor fluid levels
● Monitor renal and liver status
Amlodipine
Therapeutic class: Calcium channel blocker
Indication: Hypertension, angina
Action: Blocks transport of calcium into muscle cells inhibiting excitation and
contraction, causes peripheral vasodilation
● Avoid grapefruit
○ Blocks the enzyme involved in metabolizing calcium channel blockers, causing their levels to
increase.
● Monitor BP - orthostatic hypotension
● Can cause gingival hyperplasia
NCLEX Question
The nurse is providing discharge instructions to a client with accelerated hypertension who has been
newly started on Nifedipine. His home medications include calcium supplements for osteoporosis,
omeprazole for heartburn, furosemide, and lisinopril. Which statement(s) by the client demonstrates the
need for additional teaching regarding Nifedipine? Select all that apply.
a. “My gums may swell because of this medication.”

b. “I will avoid getting up too quickly from sitting or lying position.”
c. “I will stop taking calcium supplements since they may negate the effects of Nifedipine.”
d. “It is highly likely that I will get constipated from this drug”
e. “If I get cough and tongue swelling, I will hold Nifedipine”
Test Taking Tool
The nurse is providing discharge instructions to a client with accelerated hypertension who has been
newly started on Nifedipine. His home medications include calcium supplements for osteoporosis,
omeprazole for heartburn, furosemide, and lisinopril. Which statement(s) by the client demonstrates the
need for additional teaching regarding Nifedipine? Select all that apply.
a. “My gums may swell because of this medication.”

b. “I will avoid getting up too quickly from sitting or lying position.”
c. “I will stop taking calcium supplements since they may negate the effects of Nifedipine.”
d. “It is highly likely that I will get constipated from this drug”
e. “If I get cough and tongue swelling, I will hold Nifedipine”
Answer: C, D, and E
A is incorrect. Gum/ gingival hyperplasia is a common side effect with extended-standing use of Nifedipine.
B is incorrect. The client should avoid getting up too quickly from sitting or lying position. Because of peripheral
vasodilation, Nifedipine causes postural or orthostatic hypotension. So, the client should be aware of getting up slowly
from the lying/ sitting position so they do not become dizzy.
C is correct. The client should not stop taking their calcium supplements. There is no evidence to say oral calcium
supplements will reduce the effects of CCBs. Also, this client needs calcium supplements for his osteoporosis. Therefore,
this does not reflect correct understanding by the client and needs additional teaching.
D is correct. There is a less than 2% chance that the person can get constipated from Nifedipine, it is not true that the
client is highly likely to get constipated from Nifedipine. Therefore, this statement does not reflect correct understanding
by the client and needs additional teaching.
E is correct. The client should not hold Nifedipine if they get cough and tongue swelling. Cough and tongue swelling
(Angioedema) are common side effects seen with ACE inhibitors, not with CCBs. The client is also on Lisinopril (ACEI),
which may lead to this side effect, so the nurse will need to explain this to the client.
Beta Blockers
● Propranolol
● Atenolol
● Metoprolol
● Esmolol
● Sotalol
Propranolol
Therapeutic class: antiarrhythmic
Indication: hypertension, angina, arrhythmias, MI, cardiomyopathy, alcohol

withdrawal, anxiety
Action: blocks Beta 1 and 2 adrenergic receptors slowing the heart rate
● Do not discontinue abruptly, discontinue them slowly,

● Can mask the signs of hypoglycemia; important to monitor blood sugars.
● Caution with asthma and COPD - can potentially cause bronchospasm.
Antiarrhythmics
● Amiodarone
● Adenosine
● Atropine
Adenosine
Therapeutic class: Antiarrhythmic
Indication: SVT
Action: Slows conduction through the AV node, interrupts re-entry pathways

through AV node, restoring normal sinus rhythm
● There will be a period of asystole after administration

● Warn the client- it will feel like someone kicked them in the chest!
● Warn the family - they will flatline on the monitor!
● Rapid push - or it will not work.
● Use with extreme caution in asthmatics.
Atropine
Therapeutic class: Antiarrhythmic; anticholinergic
Indication: excessive secretions, sinus bradycardia, heart block
Action: Inhibition of acetylcholine, increasing the HR, causing bronchodilation,

and decreasing secretions.
● Monitor for urinary retention and constipation

● Avoid in clients with glaucoma
Cardiac glycosides
● Digoxin
Digoxin
Therapeutic class: Cardiac glycoside
Indication: Heart failure, a-fib, a-flutter, CHF, cardiogenic shock
Action: Increases contractility (how strong the heart pumps), and decreases the rate (how fast the heart
beats). Acts on the cellular sodium-potassium ATPase, making the heart more efficient!
Toxicity
Monitor for toxicity in any client taking digoxin!
Narrow therapeutic range!! → Therapeutic lab level: .5-2ng/mL
● Early signs/symptoms:
○ Nausea & vomiting
○ Anorexia
○ Vision changes - yellow/green halos
● Late signs/symptoms
○ Bradycardia → arrhythmias
Monitor for these signs and symptoms and report them to the health care
provider early!
Risk factors for toxicity
● Patients with hypokalemia (K<3.5)
○ **If your client is on a loop diuretic, and digoxin, they are more likely to become toxic!**
○ Licorice extract acts like aldosterone (Na/water retention & K loss) → hypokalemia → Dig
Toxicity. Licorice extract is in black licorice.
● Patients with hypomagnesemia (Mg<1.8)
● Patients with hypercalcemia (Ca>10.5)
● The elderly!
○ These clients have decreased renal and liver function, making it harder for them to clear any
drugs, so digoxin levels can build up and become toxic more quickly!
Important Nursing Consideration

When should you HOLD your digoxin dose??
In general, if the pulse is less than 60, you should hold digoxin. This will be
slightly different in different age groups. Always check your order!
Antidote: digoxin immune fab

NCLEX Question
A nurse is caring for a client receiving digoxin. The client’s most recent serum
digoxin level was 2.5 ng/mL. Which of the following essential nursing actions
should the nurse take? Select all that apply.
A. Withhold the client’s scheduled dose

B. Administer the dose as prescribed
C. Assess the client's urinary output
D. Assess the client's most recent sodium level
E. Assess the client’s heart rate and rhythm
Answer: A and E
The client’s digitalis level of 2.5 ng/mL is indicative of toxicity. Digoxin has a narrow therapeutic index, which
means it can cause significant side effects, such as cardiac arrhythmias (e.g., bradycardia, heart block, ventricular
arrhythmias), even at plasma concentrations only twice the therapeutic plasma concentration range. Normal
corrective serum digoxin levels range from 0.5 - 2 ng/mL. A level higher than two ng/mL is considered toxic. The
nurse is correct to withhold the scheduled dose (Choice A) and assess the client’s heart rate and rhythm (Choice
E) as the client is likely to be experiencing bradycardia.
Choice B, C, D, and F are incorrect. It would be wrong to administer the next dose, as this would exacerbate the
toxicity. An assessment of the urinary output and sodium is not relative to digitalis toxicity and is not the priority
here. Calling the physician to notify regarding the toxic level is appropriate, but there is no reason to obtain a 2D
echocardiogram. A 2D echocardiogram will not add any additional information at this point. Instead, an
electrocardiogram must be obtained to look for any rhythm disturbances due to digoxin toxicity.
Critical Care Medications
● Inotropes: increase the contractility of your heart
○ Dopamine
○ Dobutamine
○ Milrinone
● Vasopressors (vasoconstrictors): cause constriction of the blood vessels,
helping to increase the blood pressure
○ Norepinephrine
○ Epinephrine
○ Vasopressin
○ Phenylephrine
Antivirals
● Acyclovir
● Ganciclovir
● Remdesivir
Antifungals
● Miconazole
● Metronidazole
● Fluconazole
Antibiotics
● Gentamicin
● Erythromycin
● Azithromycin
● Vancomycin
● Ciprofloxacin
● Levofloxacin
● Amoxicillin
● Ampicillin
Vancomycin
Therapeutic class: Anti-infective; glycopeptide antibiotics
Indication: Infection; sepsis
Action: kills bacteria in the intestines
● Monitor for ototoxicity and nephrotoxicity

● Red-man syndrome
● Administer over at least 60 minutes; central line preferred.
Respiratory Medications
● Bronchodilators - Rescue meds
○ Albuterol
○ Levalbuterol
● Long-term medications
○ Guaifenesin → Expectorant
○ Montelukast → Leukotriene modifier
Also given often to respiratory clients…. Corticosteroids + antihistamines.

Albuterol
Therapeutic class: Bronchodilator; short acting beta 2 agonist
Indication: Asthma, COPD
Action: Binds to Beta2 adrenergic receptors in the airway leading to relaxation of

the smooth muscles in the airways
● Be very cautious when using in clients with heart disease, diabetes,

glaucoma, or seizures.
● Causes tachycardia
GI Medications
● Laxatives ● Antiemetics
○ Lactulose ○ Ondansetron
○ Bisacodyl ○ Promethazine
○ Milk of magnesia ● Proton-pump inhibitors
○ Polyethylene glycol ○ Omeprazol
○ Senna ○ Pantoprazole
● Stool softeners
○ Docusate
● Antidiarrheal
○ Loperamide
○ Bismuth subsalicylate
Ondansetron
Therapeutic class: Antiemetic
Indication: Nausea/vomiting
Action: blocks effects of serotonin on vagal nerve and CNS
● Administer slowly. Fast push can cause QT prolongation and VT.
Omeprazole
Therapeutic class: Proton-pump inhibitor
Indication: GERD, ulcers
Action: prevents the transport of H ions into the gastric lumen by binding to
gastric parietal cells to decrease gastric acid production
● Administer 30-60 minutes before meal

● Report black, tarry stools
Non-opioid Analgesics
● Acetaminophen
● NSAIDS
○ Acetylsalicylic Acid
○ Ibuprofen
○ Naproxen
Acetaminophen
Therapeutic class: antipyretic, non-opioid analgesic
Indication: Pain, fever
Action: Inhibit the synthesis of prostaglandins which play a role in transmission of

pain signals and fever response
● Max daily dose = 4g

○ For long term use - the maximum daily dose is only 3 grams per day!!
● Monitor liver function
● Antidote = n-acetylcysteine
NSAIDS - Non-steroidal anti-inflammatory drugs
Examples: Aspirin, ibuprofen, ketoprofen, naproxen
Indication: Pain, inflammation, fever
Action: Block prostaglandin which causes inflammation, pain, and fever.
● Can cause prolonged bleeding

○ Typically avoided in trauma and surgical clients
● Can cause peptic ulcers
Acetylsalicylic Acid (Aspirin)

Therapeutic class: Antipyretic, non-opioid analgesic
Indication: Pain - arthritis. Stroke and MI prophylaxis
Action: Inhibits the production of prostaglandins which leads to a reduction of

fever and inflammation, decreases platelet aggregation leading to a decrease in
ischemic diseases
● Risk of bleeding
○ Don’t administer with other anticoagulants
○ D/c 5-7 days prior to surgery
● Caution with pediatric clients
○ Reye’s syndrome can occur with viral infections
○ Only time it is commonly used in peds is in Kawasaki's disease
Opioids
● Morphine
● Fentanyl
● Hydromorphone
● Oxycodone
Morphine
Therapeutic class: Opioid analgesic
Indication: Pain
Action: Binds to opiate receptors in the CNS and alters perception of pain while
producing a general depression of the CNS.
● Common side effect: constipation

● CNS depressant
○ Decreased respiration, decreased heart rate, etc.
○ Monitor respiratory rate
● Antidote = naloxone
Obstetric Medications
● Tocolytics - slow contractions
○ Terbutaline
○ Magnesium-sulfate
● Oxytocics - stimulate contractions
○ Oxytocin
Magnesium-sulfate
Therapeutic class: Electrolyte
Indication: Hypomagnesemia, torsade de point, pre-eclampsia, preterm labor,

seizures, asthma exacerbation
● Monitor for hypermagnesemia

○ Confusion, dizziness, weakness, decreased reflexes
● Give IV slowly
Oxytocin
Therapeutic class: Hormones
Indication: Induction of labor; PPH
Action: Stimulates uterine smooth muscle causing it to contract
● Monitor contractions
● Monitor fetus
● Warn mother contractions will be more painful
● Monitor BP, HR, glucose, and K
Steroids
● Betamethasone
● Dexamethasone
● Cortisone
● Methylprednisolone
Methylprednisolone
Therapeutic class: Corticosteroids
Indication: Inflammation, allergy, autoimmune disorders
Action: Suppress inflammation and normal immune response
● Monitor for too much steroids

○ Cushing’s symptoms; buffalo hump
● Side effects
○ Immunosuppression
○ Hyperglycemia
○ Osteoporosis
○ Delayed wound healing
Dose Calc
Desired / Have x Vehicle
Desired = What do you WANT to give the client? (This is what the HCP
ordered, what the prescription is for, etc.)
Have= This is the quantity of medication (mgs, mcgs, grams…) that you actually
have on hand. What the label says on the bottle, what the pharmacy sent up, etc.
Vehicle= This is what that medication you have in you hand actually comes in.
You can’t see the mgs, mcgs, etc…. You CAN see the ml’s, tablets, capsules…. This
is what you will actually be able to measure out for your client.
(D/H) xV
You are passing medications on a pediatric floor

and have a client who needs his scheduled
diazepam. The order reads: 2.5 mg PO BID. You
remove the medication and the label reads:
clobazam 5 mg/mL suspension. How many
milliliters will you administer to your client?
Desired = 2.5 mg
The dose that you have is 5mg
The vehicle that medication comes in is 1 mL
(2.5mg/5mg) x 1 mL = 0.5 mLs
You will administer 0.5 mLs of diazepam to your
client
When they don’t tell you the exact desired….

● Sometimes you have to do a little extra math to find out what that DESIRED
dose is.
● Doctors often write orders based on the client's weight
● For example:
○ 15 mg/kg acetaminophen
○ The desired dose is 15 mg of acetaminophen PER kilogram that the client weighs
○ When this happens we have to multiply to find the total desired dose.
● We ALWAYS use kilograms!!
● If the problem gives you the client's weight in lbs…. Convert it to kgs FIRST!
2.2LB =
1 KG
A nurse prepares to administer

cephalosporin intravenously to a 9 month
old client who weighs 22 pounds. The vial
reads 4 mg/mL and the prescription is for 6
mg/kg q 8 hours. The nurse draws up
_______ mLs
Convert pounds to kilograms:
22/2.2 = 10 kg.
Calculate the dose desired:
6 mg x 10 kg = a total of 60 mg.
What you have: 4 mg
Vehicle it comes in: 1mL
(60 mg / 4 mg) x 1 mL = 15 mL.

The nurse will administer 15 mL of cephalosporin.
Rate
● The formula is the same… D/H x V
● Finding the desired just takes a bit more work!
● Your final answer should always be in ml/hr* - that is how our IV pumps
work!!!
Step 1: Find the desired dose: ml x kg x 60*
Step 2: D/H x V
*ONLY if the order is in minutes, you must multiply by 60 to convert to hours.

While working in the ICU, you are checking
the drip rates of your vasoactive infusions.
Your patient is ordered to have
norepinephrine running at 0.4 mcg/kg/min.
Their weight is 26kg. The concentration of
the norepinephrine bag is 20 mcg to 1 mL.
What rate should the pump be set to?
Desired dose = 0.4 mcg per kg per min

Multiply the 0.4 mcg by the weight (26 kg)
Multiply by 60 (to convert from minutes to hours):
(.4 mcg x 26 kg x 60 min) = 624 mcg/hr
Have = 20 mcg
Vehicle = 1 mL
Desired / Have x Vehicle:

624 mcg/20 mcg = 31.2 mL/hr
The pump should be set to 31.2 mL/hr

Dose Calc Worksheet
Lunch
Break
Lines, Tubes,
and Drains
Must know nursing
knowledge!
NG Tubes
What is a nasogastric tube?

● Tube inserted in the nare
that terminates in the
stomach
● Uses:
○ Enteral nutrition
○ Decompression
○ Medication administration
○ Removal of stomach contents
after an overdose
Insertion
1. Perform hand hygiene
2. Explain the procedure to the client
3. Measure from the earlobe of the client to the nose, then to the xiphoid
process. This is how deep you will insert the NG tube.
4. Mark the depth of insertion on the NG tube
5. Lubricate the tip of the tube.
6. Insert the tube to the nasopharynx, and ask the client to swallow and tuck
their chin to their chest.
7. Continue advancing the tube to the predetermined depth.
8. Secure the tube.
9. Verify placement of the NG tube.
Measurement
Placement verification
● Gold standard - x-ray visualization
● Aspiration of gastric contents
● Auscultation of air over the epigastrium
● Residuals
○ The amount of feeding that remains in the
stomach at the time of your assessment
○ Typically checked as you are preparing to start
the next feed
○ If it is greater than 500 mL, the feed should be
held.
Blakemore
What is a Blakemore tube?
● Tube inserted through the nose down
the esophagus and into the stomach
with balloons that can be inflated to stop
bleeding esophageal varices.
● Also called Sengstaken-Blakemore or
Minnesota tube.
● It puts pressure on bleeding esophageal
varices to stop the bleeding.
Nursing Must Know

MUST KEEP A PAIR OF
SCISSORS AT THE BEDSIDE IN
CASE OF EMERGENCY
If the gastric balloon becomes

displaced it can compress the
trachea and cause respiratory
arrest. If that happens, cut the
gastric balloon port to let the air
escape and restore the client's
airway.
Chest Tubes
What is a chest tube?

● Tube inserted into the pleural space
of the lungs.
● Helps to remove air or fluid that has
caused the lung to collapse
● Also placed after cardiac surgery to
help drain blood and fluid from
around the heart.
Why would our patient
need a chest tube?
● There is something in the pleural
space….and we need to get it out.
○ Air
○ Fluid
○ Blood
● This allows the lung to fully expand.
Drainage System Chambers

Nursing Considerations
● Always keep the drainage system below the level of the client's chest
● Ensure the tubing is free of kinks and draining freely
● There should be no dependent loops in the tubing
● Monitor the drainage
○ Color - serous - serosanguinous. Know WHY the client has a CT!
○ Odor - none
○ Consistency - thin-thick
○ Amount - no more than 100ml/hr. More? Call the doc!!
■ Mark hourly
What to do if the chest tube comes out

● Cover the site with a
sterile dressing
● Tape on 3 sides
○ Air can escape this way. If
you tape on 4 sides you
might cause a tension
pneumothorax
● Call the provider
● STAY WITH THE
PATIENT
Foley
Catheter
What is a foley catheter?

● Catheter placed into the urethra and up to the client's bladder
● Foley catheters are ‘indwelling’ or left for an extended period of time
● Urine drains into a drainage bag
Inserting a foley catheter
1. Wash your hands and don sterile gloves
2. Place the tip of the catheter in lubricant
3. Clean with betadine
a. Females: Use the non-dominant hand to spread the labia. Use three swabs: one on the left,
one on the right, and the last one down the middle.
b. Male: Clean the peri-urethral opening with three swabs.
4. Using the dominant hand, insert the catheter into the urethral opening
5. Once urine is observed, advance the catheter another one to two inches
6. Attach the pre-filled syringe to the port and inflate the balloon
7. Connect the drainage system to the catheter and secure per facility protocol.
Nursing Must Know

● There should never be dependent loops in the tubing. This can lead to urine
backing up in the bladder.
● Inserting a foley catheter requires sterile technique to prevent infection.
● CAUTIS (catheter acquired urinary tract infections) are UTIs caused by a
catheter. The hospital is not reimbursed for these infections, so there is a lot
of emphasis on preventing them.
○ Most facilities use a bundle to prevent CAUTIS
■ Always remove as soon as possible
■ Daily cleaning and care
● You can collect a urine sample directly from the port on the foley!
Collecting a urine sample
1. Collect supplies.
2. Wash hands, put on gloves.
3. Wipe genitals with a towelette
4. Allow urine for flow for two seconds, then place sterile container to collect
sample.
5. Client can finish urinating.
6. Replace lid on specimen container and label according to policy. Place in a
specimen bag.
7. Remove gloves, wash hands.
Endotracheal
Tube
What is an endotracheal tube (ETT)?
● Invasive, artificial airway used when the client is unable to protect their own
airway.
● Plastic tube inserted into the

tracheal through the mouth or
nose
● Maintains an airway to deliver
oxygen and positive pressure
to the lungs
● “Breathing tube”
Nursing Must Know

● After placement of an ETT, placement should be verified by a chest x-ray
● Assess for equal breath sounds bilaterally
○ The ETT can becomes displaced into the R main stem bronchus
○ Ensure that breath sounds are heard equally bilaterally or the tube may need to be
repositioned.
Tracheostomy
What is a tracheostomy tube?

● An artificial airway used for
long-term needs.
● Stoma is made in the neck and the
tube inserted into the trachea.
● Breathing is through the
tracheostomy tube, not the nose and
mouth.
● Used for:
○ Tracheal obstruction
○ Slow vent weaning
○ Tracheal damage
○ Neuromuscular damage
Nursing Must Know
● INFECTION PREVENTION
○ The natural defenses of the nose and mouth are bypassed - higher risk for infection
○ Daily trach care
○ Suctioning
● Only suction to the pre measured depth
○ Suctioning too deep can cause damage or cause laryngospasm
○ Don’t suction longer than 10 seconds
○ Some clients may need pre-oxygenated with 100% FiO2
● Safety
○ You must keep two back up trachs at the bedside incase of emergency
■ 1 of same size
■ 1 a half size smaller
○ If the trach comes out, first try to insert the back up of the same size
○ If unsuccessful, try to insert the half size smaller
Intravenous
access
Peripheral IV (PIV)
Central Venous Catheter (CVC)

● IJ
● PICC
● Hickmann
● Broviac
● TT
Isolation
Precautions
Standard
● Perform hand hygiene
● Use PPE if you expect to be exposed to bodily fluids
● Disinfect client equipment
Contact ● Infections requiring contact
● PPE to wear: precautions:
○ Gown ○ MRSA
○ Gloves ○ VRE
○ Noroviruses
● Client dedicated equipment
○ Rotavirus
○ Disposable stethoscope
○ Conjunctivitis
○ BP cuff
○ Diphtheria (cutaneous)
○ Thermometer
○ Herpes Simplex virus
● Limit transport of client ○ Human Metapneumovirus
● Appropriate client placement ○ Pediculosis (lice)
○ Single clientroom ○ Scabies
○ Same infections grouped together ○ Poliomyelitis
○ Staphylococcus aureus
C. diff
Hand sanitizer doesn’t kill C. diff spores!!
Follow contact precautions AND wash hands

with soap and water.
Infections requiring droplet precautions:
Droplet ●
○ Influenza
○ Pertussis
● PPE to wear:
○ Mumps
○ Mask
○ Rhinovirus
○ Eye cover
○ Adenovirus
■ Goggles or face shield
○ Meningitis
● Limit transport of client ○ Streptococcus Aureus
○ When transporting, place mask on ○ Rubella
client. ○ Haemophilus influenzae type B
○ Teach client to cough into elbow ■ Epiglottitis
● Appropriate client placement ○ Parvovirus
○ Single clientroom ○ Diphtheria (pharyngeal)
○ Same infections grouped together
Airborne
● PPE to wear: ● Infections requiring airborne
○ Respirator precautions:
■ N95 or PAPR
○ Tuberculosis
○ Gown** IF potential for bodily fluid exposure
○ Rubeola virus (Measles)
○ Gloves** IF potential for bodily fluid exposure
○ Varicella virus (Chickenpox)
● Airborne isolation room ○ Varicella zoster
○ Negative pressure when possible ○ SARS
○ DOOR MUST REMAIN CLOSED ○ Smallpox
○ Private room
● Appropriate healthcare personnel
○ Restrict susceptible personnel from entering
room.
○ Limit number of people needed to enter room.
● Limit transport of client
○ Put mask on clientif they must leave the room.
Donning PPE
Gown
● Fully cover torso from neck to knees, arms to end of wrist,
and wrap around the back
● Fasten in back at neck and waist
Mask or Respirator
● Secure ties or elastic band at middle of head and neck
● Fit flexible band to nose bridge
● Fit snug to face and below chin
● Fit-check respirator
Goggles/Face Shield
● Put on face and adjust to fit
Gloves
● Use non-sterile for isolation
● Select according to hand size
● Extend to cover wrist of isolation gown
Gloves
Doffing PPE
● Grasp outside of glove with opposite gloved hand;
peel off
● Hold removed glove in gloved hand
● Slide fingers of ungloved hand under remaining glove
aat wrist
Goggles/Face Shield
● To remove, handle by “clean” headband Place in
designated receptacle for reprocessing or in waste
container
Gown
● Unfasten neck, then waist ties
● Remove gown using a peeling motion; pull gown from
each shoulder toward the same hand
● Gown will turn inside out
● Hold removed gown away from body, roll into a
bundle and discard into waste or linen receptacle
Mask or Respirator
● Front of mask/respirator is contaminated – DO NOT
TOUCH!
● Grasp ONLY bottom then top ties/elastics and remove
● Discard in waste container
Restraints
When is it appropriate to use restraints?

● Is your client a danger to themselves or others?
○ Client trying to harm themself
○ Combative client trying to harm team members
● Are they trying to pull out their IVs or airway?
● Delirious clients
○ Don’t know where they are
○ Are afraid and at risk for harming themself
Always, always, ALWAYS remove the restraints as soon as possible! Use other
methods when appropriate - redirection, orientation, sedation as ordered.
Non-Violent Violent
● HCP must see client ● HCP must see client within 1
hour
within 24 hours
● RN assessment - q15 minutes
● RN assessment - q1-2 ● Restraint order expires in:
hrs depending on unit ○ Adults: 4 hours
policy ○ 9-17 y.o: 2 hours
○ <9 y.o: 1 hour
● Restraint order expires
in 24 hours
Document, document, document!
What MUST be documented when you have a client in restraints:
● Reason restraints are indicated

● Start and stop times
● Plan of care
● Assessment
○ ESPECIALLY important to check for skin breakdown
○ Look at skin under all restraints, note any redness, and use preventative measures to protect
skin.
○ Required to release at least every 2 hours to fully assess
NCLEX Question
Which of the following situations represents an appropriate time to place your
client in restraints?
a. When they are trying to pull at their lines, tubes, and drains.
b. When their family member asks you to.
c. When you feel it is necessary.
d. When the family feels they are a danger to themselves.
Answer: A
A is correct. It is appropriate to place your client in restraints, with an order from your healthcare provider, if the
client is trying to pull out their lines, tubes, and drains. This makes them a danger to themselves and can cause
harm, so restraints may be appropriate.
B is incorrect. A family member may request restraints, but this is not an appropriate reason to initiate restraints.
You should explain to the family member other options and what you are trying to do for their loved one before
initiating restraints.
C is incorrect. Just because you feel that restraints are necessary does not mean you may initiate them. You must
speak with your healthcare provider and explain why you think restraints are necessary to obtain an order.
D is incorrect. If your client is a danger to themselves, and other interventions are not keeping them safe, it is
appropriate to request an order for restraints from your healthcare provider. However, the nurse needs to assess
this herself. To make this determination, not just based on the family’s opinion.
NCSBN Client Need:

Topic: Effective, safe care environment Subtopic: Coordinated care
Reference: DeWit, S. C., Stromberg, H., & Dallred, C. (2016). Medical-surgical nursing: Concepts & practice. Elsevier Health Sciences.
Subject: Fundamentals
Lesson: Safety
Growth &
Development
Theories of psychosocial development
Infants
● Erikson's stages of psychosocial development
○ Trust vs. mistrust: Birth - 18 months
● Piaget's stages of Cognitive development
○ Sensorimotor: Birth - 2 years
● Social smile: 6-8 weeks

● Object permanence: 9 months
● Stranger anxiety: 9 months
Toddlers
● Erikson stage:
○ Autonomy vs. Shame and Doubt - 18mo-3 years
● Piaget stage:
○ Preoperational stage - begins at age 2
● Parallel play
○ Children play adjacent to each other, but do not try to influence one another's behavior.
● Symbolic play
○ The ability of children to use objects, actions or ideas to represent other objects, actions, or
ideas as play.
Preschoolers
● Erikson stage
○ Initiative vs. Guilt - 3-5 years
● Piaget stage
○ Still preoperational unil 7 years
● Cooperative play
○ Play that involves the division of efforts among children in order to reach a common goal.
● Magical thinking
○ The belief that one's own thoughts, witheys, or desires can influence the external world.
● Do not yet have a concept of time
School Age
● Erikson stage
○ Industry vs. Inferiority: 5-13 years
● Piaget stage
○ Concrete operational stage: 7-11 years
● Social interaction with peers prioritized over family
Adolescents
● Erikson stage
○ Identity vs. confusion: 13-21 years
● Piaget stage
○ Formal operational stage: 12+years
● Risky behavior increases

Young Adults
● Erikson stage:
○ Intimacy vs. Isolation: 21 - 39 years
Middle Adults
● Erikson stage:
○ Generativity vs. stagnation: 40-65 years
Old Adults
● Erikson stage:
○ Integrity vs. Despair: 65+ years
Cultural
Considerations
Orthodox Jewish
● Kosher
○ No shellfish
○ No pork
○ Do not combine meats and dairy products in the same meal.
● Client will need wrapped plastic utensils and they will unwrap the utensils
and prepare their own meal
Islam
● Muslim faith
● Halal
○ No alcohol
○ Meat slaughtered religiously
○ No pork
● Ramadan
○ Fast during daylight hours
● Women will typically require a female provider for their care
● Prayer
○ 5 times a day
Hinduism
● Hindus practice ayurvedic medicine, which encompasses all aspects of life,
including diet, sleep, elimination, and hygiene.
● Most Hindus are lacto-vegetarians.
○ No eggs
○ No fish or other meat
○ Dairy - okay!
● Fasting usually means eating only pure foods, such as fruit or yogurt, but is
not expected of the sick.
Other considerations
● Jehovah’s Witness
○ May refuse blood transfusion
● Catholicism
○ May fast during lent
● Mormons
○ No caffeine
○ No alcohol
Using interpreters
● Do not use a family member
● Certified medical interpreter
● Speak to the client- not to the interpreter
● Ask one question at a time
“If it isn’t culturally and linguistically appropriate, it isn’t

healthcare”
-Marjory Bancroft, Director of Cross-Cultural Communications
End of life care

● Chinese
○ Often do not discuss death and end of life - seen as hopelessness
○ May wish to use alternative therapies or herbal remedies
● Muslim
○ Help facilitate times of prayer
○ May request to be facing Mecca
● Different cultures have specific views about the end of life
● Important to remember that every person is unique

● Do not make any assumptions
● Ask the client and their family members about their wishes to provide the
best care.
End of Part I!
Break Back at….
Part II: System

by System
Cardiac
Blood flow through the heart

Cardiac cycle
Electrical conduction system
EKGs
What the EKG means
P wave:
Atrial depolarization
QRS complex:
Ventricular depolarization
T wave:
Ventricular repolarization
Measuring the EKG
1 second
0.04 sec
6 second strip
HR: 7 x 10 = 70
P-wave: normal
PR Interval: 0.12-0.20
QRS: <0.12
Rate: 60-100
Regularity: Regular
Normal Sinus Rhythm
P-wave: Normal Causes: Interventions:

PR Interval: 0.12-0.20 -Sleep -Fix the cause
QRS: <0.12 -Inactivity -Atropine
Rate: <60 -Very athletic
Regularity: Regular -Drugs
-MI
Sinus Bradycardia
PR Interval: 0.12-0.20 -Caffeine -Fix the cause
QRS: <0.12 -Exercise
Rate: >100 -Fever
Regularity: Regular -Anxiety
-Drugs
-Pain
Sinus Tachycardia -Hypotension
-Volume depletion

PR Interval: >.20 -Often an incidental finding -Fix the cause
QRS: <0.12 -Peds: infection -Treatment generally not
Rate: 60-100 -Myocarditis required
Regularity: Regular -Congenital heart disease -If extreme - pacing
First degree heart block

Causes: Interventions:
P-wave: Not a P for every QRS
-Ischemia -Fix the cause
PR Interval: longer, longer, longer….drop
-Myocarditis -Asymptomatic: no
QRS: <0.12
-Status post-cardiac surgery treatment required
Rate: 60-100
-Symptomatic: Pacing
Regularity: Regular
-
Second degree heart

block - type 1
P-wave: Not a P for every QRS Causes: Interventions:

PR Interval: 0.12-0.20 -MI -Fix the cause
QRS: <0.12 -Ischemia -Pacing
Rate: >100 -
Regularity: Regular
Second degree heart

block - type 2
PR Interval: Variable -Damage to the heart -Fix the cause
QRS: <0.12 -MI -Pacing
Rate: <60 -Heart valve disease
Regularity: Irregular -Rheumatic fever
-Sarcoidosis
Third degree heart block
P-wave: “saw-tooth” Causes: Interventions:

PR Interval: none -Heart disease -Fix the cause
QRS: <0.12 -MI -Cardioversion
Rate: 250-400 -CHF -Pacing
Regularity: Regular or Irregular -Pericarditis -Antiarrhythmics: amiodarone
-Beta blockers: metoprolol
-Calcium channel blockers: diltiazem
Atrial Flutter
P-wave: ‘wavy’ Causes: Interventions:
PR Interval: none -Heart Disease -Fix the cause
QRS: <0.12 -Pulmonary Disease -Cardioversion
Rate: >400 -Stress -Antiarrhythmics: amiodarone
Regularity: irregular -Alcohol -Beta blockers: metoprolol
-Caffeine -Surgery: ablation
Atrial Fibrillation
ing.
t h r eaten e,
e lerat
be lif
CAN clients to T!
Some me do NO
so
P-wave: hidden Causes: Interventions:

PR Interval: immeasurable -Caffeine -Fix the cause
QRS: <0.12 -CHF -Cardioversion
Rate: 150-250 -Fatigue -Adenosine
Regularity: Regular -Hypoxia
-Altered pacemaker in heart
Supraventricular Tachycardia (SVT)

AT E NING
F E - T HRE MIA!!
LI HYTH
A R R
P-wave: none Causes: Interventions:

PR Interval: none -MI -Fix the cause
QRS: >0.11 - ‘wide & bizarre’ -Ischemia
Rate: 150-250 -Digoxin toxicity YES pulse
Regularity: Regular -Hypoxia Cardioversion
-Acidosis
-Hypokalemia No pulse
-Hypotension -CPR
-Defibrillate
Ventricular Tachycardia (V-Tach) -Epinephrine
AT E NING
F E - T HRE MIA!!
LI HYTH
A R R
Causes:
P-wave: none -MI Interventions:
PR Interval: none -Ischemia -Fix the cause
QRS: none -Hypoxia -CPR
Rate: none -Acidosis -Defibrillate
Regularity: Irregular -Hypokalemia -Epinephrine
-Hypotension
-Most common cause of sudden death
Ventricular Fibrillation (V-fib)

LIFE- NG!!!
RE ATENI
TH
P-wave: none Causes: Interventions:

PR Interval: none -Follows VT/VF in cardiac arrest -Fix the cause
QRS: none -Acidosis -CPR
Rate: none -Hypoxia -Epinephrine
Regularity: n/a -Hypokalemia
-Hypothermia
-Overdose
Asystole
Hemodynamics
● Preload
○ Amount of blood returning to right side of the heart
● Afterload
○ Pressure against which the left ventricle must pump to eject blood
● Compliance
○ How easily the heart muscle expands when filled with blood
● Contractility
○ Strength of contraction of the heart muscle
● Stroke volume
○ Volume of blood pumped out of the ventricles with each contraction
● Cardiac output
○ The amount of blood the heart pumps through the circulatory system in a minute
Cardiac Output
WHY is cardiac output SO important?!
● Tissue perfusion!
● End organ function
● Delivery of oxygen and nutrients to each and every cell in the body!
● Poor cardiac output??
○ Decreased LOC (not enough blood flow to the BRAIN)
○ Chest pain, weak peripheral pulses (not enough blood flow to the HEART)
○ SOB, crackles, rales (not enough blood flow to the LUNGS)
○ Cool, clammy, mottled extremities (not enough blood flow to the SKIN)
○ Decreased UOP (not enough blood flow to the KIDNEYS)
CO = SV X HR
Causes of Causes of
DECREASED CO INCREASED CO
● Bradycardia
● Arrhythmias ● Increased blood
○ Pulseless v-tach volume...sometimes
○ V-fib ● Tachycardia...sometimes
○ Asystole ● Medications
○ SVT ○ ACE Inhibitors
● Hypotension ○ ARBS
● MI ○ Nitrates
● Cardiac muscle disease ● Inotropes
Hypertension
What is hypertension?
High blood pressure!
Normal <120/80
Elevated 120-129/80
Hypertension >130/>80
Hypertensive Crisis >180/>120
Causes & Risk Factors

● Family history
● African american race
● Increased age
● Obesity
● HLD
● CAD
● Stress
● Smoking
● High salt intake
● Caffeine
Assessment
● Often asymptomatic until severe
● Vision changes
● Headaches
● Dizziness
● Nosebleeds
● SOB
● Angina
Complications
● Stroke
● MI
● Renal Failure
● Heart Failure
● Vision loss
Treatment & Education
● Medications
○ ACE inhibitors
○ Beta Blockers
○ CCB
○ Diuretics
● Diet
○ DASH
○ Low salt
○ Avoid caffeine and alcohol
○ Weight loss
○ Smoking cessation
● Lifestyle
○ Less sitting more walking
NCLEX Question
A hypertensive client has prescribed antihypertensive medication. The client tells
a clinic nurse that they prefer to take an herbal substance to help lower their
blood pressure. Which is the most appropriate response for the nurse?
A.Tell the client that herbal substances unsafe and should never be used
B. Encourage the client to discuss the use of herbal substances with their
attending physician
C. Teach the client how to take their blood pressure and ask their to monitor
it every fifteen minutes
D. Tell the client that if they takes the herbal substance it will require the
nurses to check her blood pressure closely
NCLEX Question
A hypertensive client has prescribed antihypertensive medication. The client tells
a clinic nurse that they prefer to take an herbal substance to help lower their
blood pressure. Which is the most appropriate response for the nurse?
A. Tell the client that herbal substances unsafe and should never be used
B. Encourage the client to discuss the use of herbal substances with their
attending physician
C. Teach the client how to take their blood pressure and ask their to monitor it
every fifteen minutes
D. Tell the client that if they takes the herbal substance it will require the
nurses to check her blood pressure closely
Answer: B
The most appropriate response is B. Although the use of herbal substances may
have some beneficial effects, not all herbs are safe to use. Clients who are on
conventional medication therapy are discouraged from using herbal materials
with similar pharmacological effects because the combination may lead to an
excessive reaction of unknown interaction effects. The nurse would advise the
client to discuss the use of the herbal substance with their attending physician.
Options A, C, and D are inappropriate nursing actions.
Coronary Artery Disease
(CAD)
What is coronary artery disease?

● The most common type of cardiovascular disease.
● Includes two types
○ Chronic stable angina
○ Acute coronary syndrome (aka MI)
Chronic Stable Angina
● Chronic disease caused by
narrowing of coronary arteries and
plaque build up.
● There are periods of decreased
blood flow to the heart muscle
● Decreased blood flow leads to
decreased oxygen, and ischemia.
● Ischemia causes chest pain
Treatment
● Nitroglycerin
○ Venous and arterial dilation → decreased afterload → increased CO
○ Given sublingual
○ Administer 1 pill q5 minutes for 3 doses
○ Do not swallow
○ Keep in a dark bottle in dry, cool place
○ Expected side effect = headache
Education
● DECREASE THE WORKLOAD OF THE HEART!
○ Rest
○ Do not overeat
○ No caffeine
○ Avoid temperature extremes
○ No smoking
○ Promote weight loss
○ Reduce stress
Myocardial Infarction
(MI)
What is a myocardial infarction
Myocardial infarction = acute coronary syndrome = unstable angina
● There is decreased blood flow to the heart, leading to decreased oxygen,

and not only ischemia, but also necrosis.
● Goal is to act quickly and limit the damage.
Assessment
● Chest pain
○ Crushing
○ Radiating to left arm or jaw
○ Between shoulder blades
● Epigastric discomfort/indigestion
● Fatigue
● SOB
● Vomiting
Treatment
● Cath lab within 90 minutes for PCI
○ Especially important if it’s a STEMI!
MONA
● Oxygen
● Nitroglycerin
● Morphine
● Aspirin
Education
● Quit smoking
● Diet
○ Low fat
○ Low salt
○ Low cholesterol
● Exercise
○ Avoid isometric exercises
○ Walking is a good choice
NCLEX Question
A 45-year-old man is rushed to the ER with reports of substernal chest pain and
diaphoresis. Cardiac troponin levels were taken and found to be elevated. The ER
nurse understands that nursing interventions would focus on which priority?
A. Increase oxygenation to the heart and reduce the heart’s workload

B. Prevent complications and confirm a diagnosis of myocardial
infarction
C. Alleviate the client's anxiety
D. Pain relief
Correct answer: A
A is correct. The client is showing signs and symptoms of myocardial infarction. The
priority for nursing care should be focused on increasing oxygen delivery to the heart and
reducing its workload to prevent further damage.
B is incorrect. Confirming the diagnosis should be done; however, since the client is already
exhibiting signs of reduced myocardial oxygenation (chest pain), the nurse should prioritize
oxygen delivery to the client.
C is incorrect. It is the nurse’s responsibility to alleviate the client’s anxiety; however, the
nurse should prioritize oxygenation to the client.
D is incorrect. Pain relief should be important in the care of the client with myocardial
infarction; however, it should not take priority over myocardial oxygenation.
Heart Failure
What is heart failure?

The inability of the heart muscle to pump enough blood to meet the body's
needs for blood and oxygen.
● Often results as a complication of other diseases

● #1 cause of HF is hypertension
● Other causes:
○ Cardiomyopathy
○ Endocarditis
○ MI
● Two types: Left and Right
Left-sided Heart Failure
Left side of the heart cannot move blood forward to the body.
Blood is backing up in the LUNGS.
Assessment:
● Pulmonary congestion
● Wet lung sounds
● Dyspnea
● Cough
● Blood tinged sputum
● S3
● Orthopnea
Right Heart Failure

Right side of the heart cannot move blood forward to the lungs.
Blood is backing up in the BODY.
Assessment:
● Jugular venous distention

● Dependent edema
● Hepatomegaly
● Splenomegaly
● Ascites
● Weight gain
● Fatigue
● Anorexia
Treatment
● DECREASE THE WORKLOAD OF THE HEART!
● Primary strategy is to decrease afterload:
○ ACE Inhibitors
■ Arterial dilation→ decreased afterload → Increased stroke volume
○ ARBS
■ Decrease BP → decreased afterload → Increased CO
● Increase contractility
○ Digoxin
● Diuresis
○ Pt needs help reducing excess fluid
Education
● Take diuretic medications in the AM
● Monitor electrolyte levels while on diuretics
● Low sodium diet
○ This helps decrease fluid
● Elevate the HOB
○ Will help with diuresis
● Daily weight
○ Same time
○ Same scale
○ Same clothes
● Report any increase of 2-3 lbs in one day
Shock
What is shock??
● A state where the vital organs are not receiving adequate oxygenation.
● This lack of oxygenation causes organ damage and forces the cells to use
anaerobic metabolism to create energy….producing lactate.
● Cardiovascular system is composed of:

○ The blood
○ The vasculature
○ The heart
● A disruption in any of these three components can cause a lack of oxygen
delivery to the organs, causing shock.
● Which component is ‘broken’ determines the type of shock.
Hypovolemic Shock
Pathophysiology
● Low blood flow
● There is a loss of the circulating volume
● Not enough blood to enter the heart (preload),
which decreases cardiac output.
● The body will vasoconstrict to compensate.
Causes
● Hemorrhage
● Traumatic injury
● Dehydration
○ Vomiting
○ Diarrhea
● Burns
Assessment
○ Weak
○ Pale
○ Tachycardic
○ Anxious
○ Hypotension
○ Decreased LOC
○ Pale
○ Cool
○ Clammy
○ Decreased UOP
Treatment
● Fix the cause
○ Stop vomiting/diarrhea
○ Stop bleeding
■ Repair in OR
● Replace volume
○ Isotonic IVF
■ NS
■ LR
○ Blood products
● Support perfusion
○ Vasopressors
Cardiogenic Shock
Pathophysiology
● The heart fails to pump sufficient blood out to the organs
● “Pump failure”
● Something is stopping the heart itself from getting blood out to the body
● Without sufficient blood delivered to the body, there is inadequate
oxygenation
● Lack of oxygen impairs normal cellular metabolism
Causes
● MI
● Cardiac tamponade
● Pulmonary embolism
Assessment
● Decreased perfusion
○ Hypotension
○ Weak pulses
○ Cool, pale, clammy
○ Decreased UOP
○ Decreased LOC
● Volume overload
○ JVD
○ Crackles
○ SOB
○ Muffled heart sounds
○ S3
Treatment
● TREAT THE CAUSE
○ MI
■ PCI
■ CABG
○ PE
■ Thrombolytics
○ Tamponade
■ Pericardiocentesis
● Improve contractility
○ Dopamine
○ Dobutamine
● Decrease afterload
○ Diuretics
○ Dobutamine
Distributive Shock
Pathophysiology
● Something causes an immune or autonomic response in the body
● This alters vascular tone
● The result is massive peripheral vasodilation
● With so much vasodilation, the blood pressure is inadequate to provide
blood flow to the vital organs.
● Without sufficient blood delivered to the body, there is inadequate
oxygenation
● Lack of oxygen impairs normal cellular metabolism
Causes
● Anaphylactic
○ Allergic reaction
● Neurogenic
○ SCI
● Septic
○ Systemic infection
○ Causes release of inflammatory cytokines
Assessment
● Decreased oxygen
● Hypotension
● Tachycardia
● Tachypnea
● Warm, flushed skin
● Decreased LOC
Treatment
● Anaphylactic
○ Epinephrine
○ Corticosteroids
○ Bronchodilators
● Neurogenic
○ Cooling
○ Supportive care
● Septic
○ IV antibiotics
○ IVF
Break
Back at….
Respiratory
Respiratory System Anatomy
Gas exchange
The delivery of oxygen from the lungs to the bloodstream, and the elimination of
carbon dioxide from the bloodstream to the lungs. Occurs in the alveoli through
passive diffusion.
Terminology
● Ventilation
○ Air movement in and out of the lungs
● Oxygenation
○ Oxygen in the bloodstream
● Perfusion
○ Oxygen in the tissues
*TIP* - remember you can play these videos directly from the PDF!
“Work of breathing”
Chronic Obstructive
Pulmonary Disease
(COPD)
What is Chronic Obstructive Pulmonary Disease?
● A group of lung diseases that

block airflow and make it
difficult to breathe.
● Includes:
○ Emphysema
○ Chronic bronchitis
○ Asthma
● Damage is not reversible.
Categories
● Emphysema
○ Destruction of alveoli is due to chronic inflammation. There is decreased surface area of
the alveoli for participation in gas exchange.
● Chronic Bronchitis
○ There is chronic inflammation with a productive cough and excessive sputum
● Asthma
○ A respiratory condition marked by spasms in the bronchi of the lungs, causing difficulty
in breathing. There is chronic inflammation of bronchi and bronchioles, and excess
mucus.
Assessment
● Barrel chest
● Accessory muscle use
○ Retractions
○ Nasal flaring
○ Tracheal tug
● Congestion
● Lung sounds
○ Diminished
○ Crackles
○ Wheezes
● Acidotic
● Hypercarbic
● Hypoxic
Treatment
● Be very careful with oxygen administration!
○ In the normal client, hypercarbia stimulates the body to breathe.
○ This client has been hypercarbic for an extended period of time
○ For them, hypoxia has become the driving factor to stimulate breathing
● Bronchodilators
● Chest physiotherapy
● Increased fluid intake
● Encourage pursed lip breathing to help expire completely.
● Eat small frequent meals to avoid overdistention of the stomach which
impedes the diaphragm.
Asthma
What is Asthma?
● A respiratory condition marked
by spasms in the bronchi of the
lungs, causing difficulty in
breathing.
● Chronic inflammation of bronchi
and bronchioles.
● Excess mucus.
● Result of an allergic reaction or
hypersensitivity.
Pathophysiology
1. Airway is abnormally reactive - heightened sensitivity
2. Trigger causes a response
3. Inflammation and excess mucus production occur
4. Bronchospasm decreases the airway diameter
5. Airflow becomes obstructed
After many asthma reactions, airway remodeling occurs which causes scarring
and changes to lung tissue.
Triggers
A - Allergens
S - Sport / Smoking
T - Temperature change
H - Hazards
M - Microbes
A - Anxiety
Assessment
● Unable to speak
○ Evaluate how many works they can say before taking a breath
● Cough
● Increased work of breathing
○ Retractions
○ Tracheal tug
○ Head bobbing
● Wheeze
● Prolonged expiration
● Can’t hear any breath sounds? Complete obstruction.
Complication - Status Asthmaticus

● Asthma attack that is refractory to
treatment
● Leads to severe respiratory failure
● Can progress to death if untreated
Treatment - acute exacerbation
● Airway, breathing, circulation!!
● Oxygen administration
● B-Adrenergic agonists
■ Open up airway
■ Albuterol
● Corticosteroids
■ Can be given IV, IM or PO
● Ipratropium Bromide
● Magnesium sulfate
Treatment - long-term control

● Inhaled Corticosteroids
○ Budesonide & Fluticasone
○ Take daily
● Leukotriene modifiers
○ Montelukast sodium
○ Blocks leukotrienes from over responding to triggers
● Theophylline
○ Bronchodilator
○ Helps keep bronchioles open and prevent wheezing, but must be used regularly.
● Allergen control
○ Clean environment
○ Minimize dust, pet dander, and mold
○ No secondhand smoke
Pneumonia
What is Pneumonia?
● Inflammation of the lung affecting the alveoli
● Alveoli
○ Tiny air sacs of the lungs which allow for gas exchange
● Alveoli become filled with pus and liquid
Classifications
● Viral
○ Caused by viruses such as RSV, adenovirus, and influenza
● Bacteria
● Fungal
● Chemical irritation
● Aspiration
○ When foreign bodies such as food and secretions enter the lungs
○ Cause inflammation and infection leading to pneumonia
Diagnosis
● Chest x-ray
○ “Patchy infiltrates”
● Sputum culture
○ Will identify a bacterial source
Assessment
● High fever
● Cough
● Tachypnea
● Crackles
● Chest pain
● Work of breathing
○ Retractions
○ Tracheal tug
○ Nasal Flaring
○ Grunting
○ Head bobbing
Treatment
● Maintain airway ● Chest physiotherapy
○ Suction
● Antipyretics
○ Monitor SpO2
● Monitor breathing ● Analgesia
○ Assess for increased work of breathing ● Cough suppressant
○ Provide support as needed ● Expectorants
○ Humidified oxygen ● Antibiotics if bacterial
● Maintain circulation ● Isolation
○ Monitor for dehydration
○ IVF if unable to tolerate PO
NCLEX Question
The nurse is reviewing the discharge teaching with a family who will be taking their
12 year old diagnosed with pneumonia home today. Which of the following points
should they review? Select all that apply.
a. Encourage your child to drink lots of water.

b. Administer the full course of antibiotics, even if your child starts to feel
better.
c. Call your pediatrician if there is tan sputum when when child coughs
d. Administer ibuprofen if your child has a temperature greater than 100
degrees F.
Answer: A and B
A is correct. It is appropriate teaching to have the parents encourage their child to drink lots of water. Pneumonia can
frequently cause dehydration, due to tachypnea and increased insensible fluid losses. Parents should encourage adequate
hydration to promote fluid and electrolyte balance while their child is recovering from pneumonia.
B is correct. It is very important to teach parents to administer the full course of antibiotics, even if their child starts to feel
better. If the parents stop administering antibiotics part of the way through the course, they will be promoting antibiotic
resistance and the chance that the infection could return.
C is incorrect. The parents do not need to call the pediatrician if there is tan sputum when the child coughs. This is a
normal finding of pneumonia and should be expected. If there is a new onset of green sputum, this could indicate the
development of a bacterial pneumonia and the need to call the pediatrician.
D is incorrect. While Ibuprofen does have some antipyretic properties, it is not the best choice of medication to treat a
fever. If the child has a temperature of 100 F, the parents should be educated to administer acetaminophen, which is the
first choice for an antipyretic medication.
NCSBN Client Need:
Topic: Health promotion and maintenance Subtopic:-
Reference: Hockenberry, M., Wilson, D. & Rodgers, C. (2017). Wong’s essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited.
Subject: Pediatric
Lesson: Respiratory
Acute Respiratory Distress
Syndrome
(ARDS)
What is ARDS?
● “an acute condition
characterized by bilateral
pulmonary infiltrates and
severe hypoxemia in the
absence of evidence for
cardiogenic pulmonary
edema”
● Fluid collects in alveoli

● Deprives body of oxygen
Pathophysiology
● Inflammatory response in the lungs causes an injury to the capillary
endothelium basement membrane, interstitial space, and alveolar epithelium
of the pulmonary system.
● The damage to the lungs causes increased capillary membrane permeability
allowing fluid to fill the alveoli. This impairs gas exchange.
● The products of cell damage cause the formation of a hyaline membrane,
which further prevents oxygen exchange.
● With impaired gas exchange, respiratory acidosis occurs.
● The damage to the lungs that occurs can not be reversed.
Causes
Anything that causes an inflammatory reaction in the lungs!!
● Sepsis
● Trauma
● Burns
● Aspiration pneumonia
● Overdose
● Near drowning
Assessment
● Chest x-ray
○ Diffuse bilateral infiltrates
○ “Whited-out”
● Hypoxemia
○ Pale
○ Cool
○ Dusky
○ Mottled
○ Low SpO2
Treatment
TREAT THE UNDERLYING CONDITION
● Intubation and mechanical ventilation

○ High pressures
● Prone
● Prevent infection
○ VAP
● Prevent barotrauma
Ventilator Alarms
High Pressure Alarms Low Pressure Alarms
Pressure in the circuit is too high. Pressure in the circuit is too low.
Causes: Causes:
Client coughing Tubing is disconnected
Gagging Loose connections
Bronchospasm Leak
Fighting the ventilator Extubation
ETT occlusion Cuffed ETT or trach is deflated
Kink in the tubing Poorly fitting CPAP/BiPAP mask
Increased secretions
Thick secretions
Water in ventilator circuit
Pulmonary Embolism
What is a Pulmonary Embolism?
● Life threatening blood clot in the lungs
● Can be caused by an embolism from a vein entering the lung, or a clot during
surgery.
● The clot decreases perfusion causing hypoxemia
● Can lead to right heart failure if untreated.
Assessment
● Anxiety
● Dyspnea
● Chest pain
● Hypoxemia
● Rales
● Diaphoresis
● Hemoptysis
Treatment and Nursing Interventions
● Anticoagulants
● Thrombolytics
● Positioning
○ High fowler’s
○ Promotes maximum lung expansion and assists with breathing
Air embolism
● Air embolism:
○ Air bubble enters a vein or artery
○ Very rare
○ Complication of surgical procedure
■ High risk: placement of CVC or arterial catheter
● Positioning:
○ Durant’s maneuver
■ Left lateral trendelenburg
○ This should prevent an air embolism from lodging in the lungs. Will stay in the right heart.
Break Back at….
Neurology
Anatomy & Physiology
Occipital: Vision
Lobes of the brain Temporal: Memory, understanding language
Parietal: Perception, math, spelling, logic
Frontal: Thinking, planning, organizing,

problem solving, emotions, behavioral control,
personality
Cerebellum: Balance
*Language centers:
Broca’s area: expressive language

Wernicke’s area: receptive language
Meninges
Connective tissue covering the CNS
Cerebrospinal fluid
A clear, colorless liquid found in your brain and spinal cord.
Intracranial Pressure
● The pressure inside of the skull
● Normal = 5-15
● Monro-Kellie hypothesis
○ The skull is a rigid container filled with: blood, brain, and CSF. If one of those three increases,
another must decrease.
● Causes of increased ICP:
○ Tumor
○ Bleeding
○ Hydrocephalus
○ Edema
r a v e l e d A nd
Cranial Nerves
O h , O h , T hey T Very
Oh, u a rd i n g
ort G
I - Olfactory (smell)
d V o l d e m xes
Foun r u
II - Optic (vision)
t ) H o r c
III - Oculomotor (pupil constriction)
e c r e t ( A n cien
IV - Trochlear (downward movement of eyes) S
V - Trigeminal (jaw movement, sensation of face and neck)
VI - Abducens (lateral movement of eyes)
VII - Facial (facial movement, taste on anterior 2/3 of tongue)
VIII - Vestibulocochlear (hearing and balance)
IX - Glossopharyngeal (swallowing, taste on posterior 1/3 of tongue)
X - Vagus (swallowing, speaking)
XI - Spinal/Accessory (flexion and rotation of head)
XII - Hypoglossal (tongue movements)

Skull Injury
● Basilar skull fracture
○ Battle’s sign → Bruising over the
mastoid process
○ Raccoon eyes → Periorbital bruising
○ Cerebrospinal rhinorrhea
■ Test drainage for CSF
● Halo test
● Glucose
○ NEVER INSERT AN NG TUBE IN A
client WITH A BASILAR SKULL
FRACTURE
● Open fracture → Torn dura
● Closed fracture → Dura is intact
Epidural Hematoma
● Rupture to the middle meningeal artery
● Fast bleed
● High pressure
● Characteristic pattern of symptoms:
○ Injury → loss of consciousness → recover → body compensates and they seem okay → body
is unable to compensate anymore and neuro changes begin
■ Agitation
■ Restlessness
■ Pupil change
● “Talk and die phenomenon” - medical emergency
● Treatment - burr hole
Subdural Hematoma
● Venous bleed
● Slower and less pressure
● Commonly seen in chronic geriatric clients
● Treatment: craniotomy
Hydrocephalus
What is hydrocephalus?
● Increased accumulation of cerebrospinal fluid
● Increases ICP
● Causes:
○ Tumor
○ Hemorrhage
○ Infection
○ Congenital
External Ventricular Drain (EVD)

VP Shunt
○ Ventricle - Space in the brain

○ Peritoneum - Serous membrane
lining the abdominal
compartment
○ Shunt that drains extra CSF
from brain to the abdomen,
where it can then be excreted
as urine.
Meningitis
What is Meningitis?
● Inflammation of the spinal cord or brain.
● Caused by a virus or bacteria.
○ Bacterial is more dangerous
Assessment
● Nuchal rigidity
● Photophobia
● Kernig’s sign
● Brudzinski’s sign
Treatment
● Steroids
● Analgesics
● Antibiotics - only if bacterial!!
● Isolation precautions
○ Viral - contact precautions
○ Bacterial - Droplet precautions
■ Bacterial meningitis is VERY contagious!! Medical emergency!!
● Prevention
○ Hib vaccine
○ Recommended for college students due to living in close quarters in dorms
Spinal Cord Injury
(SCI)
What is a Spinal Cord Injury?

● Damage to the spinal cord causes permanent changes in strength, sensation and other
body functions below the site of the injury.
● Symptoms depend on location of the injury
● The higher the injury - the more function that is lost.
● Injuries above T6:
○ Monitor for autonomic dysreflexia
Autonomic dysreflexia
● Syndrome characterized by
○ Sudden severe hypertension
○ Bradycardia
○ Headache
○ Nasal stuffiness
○ Flushing
○ Sweating
○ Blurred vision
○ Anxiety
Treatment
1. Sit the client up to lower their BP
2. Antihypertensives
a. Hydralazine
3. Find the cause and treat
a. Full bladder? Cath
b. Constipated? Remove impaction
c. Pressure injury? Reposition
d. Painful stimuli? Remove stilumi
e. Cold room? Change the temperature
Stroke
What is a stroke?
“A disease that affects the arteries leading to and within the brain. It is the No. 5 cause of death and a
leading cause of disability in the United States. A stroke occurs when a blood vessel that carries
oxygen and nutrients to the brain is either blocked by a clot or bursts”
…..There is a lack of oxygen to the brain, and that causes damage!

This lack of oxygen can be:
● Hemorrhagic
● Ischemic
○ Embolic
○ Thrombotic
Pathophysiology - Hemorrhagic stroke

● A vessel ruptures and bleeds into the brain.
● As the blood accumulates, there is increased pressure on the brain
● The rupture can be caused by a weakened vessel, such as in an aneurysm.
“Worst headache of my life”

Pathophysiology - Ischemic stroke
● Blood flow to the brain is blocked by a blood clot.
○ Thrombotic - a blood clot (thrombus) in an artery going to the brain. Onset in a stepwise fashion.
○ Embolic - a clot that’s formed elsewhere (usually in the heart or neck arteries) travels in the bloodstream
and clogs a blood vessel in or leading to the brain. Sudden onset!
● There is a loss of blood circulating to this area of the brain.
● The lack of blood leads to a lack of oxygen, causing ischemia and damage.
Assessment
● FAST
○ Facial droop
○ Arm drift
○ Speech problems
○ Time - call 911 ASAP - Time is brain cells!
● Altered LOC
○ Confusion
○ Lethargy
○ ‘Not acting right”
● Aphasia
● Apraxia
● Loss of vision
○ Abnormal pupil response
○ Hemianopia
● Dysphagia
Treatment
Ischemic Hemorrhagic
● Permissive hypertension ● Get the bleeding under control

○ Ensure there is perfusion to the brain ● If caused by an aneurysm:
● Antithrombotics ○ Coiling - IR
○ tPA ○ Clipping - OR
○ Break up clot to restore blood flow ● Craniotomy
○ Must be done quickly - door to tPA = 60 ● EVD
min
● Percutaneous thrombectomy
○ Surgical removal of clot
○ Done in IR
NCLEX Question
You are working in the Emergency Department when a client with a suspected
stroke arrives. Which of the following essential nursing actions should the nurse
perform? Select all that apply.
A. Activate the stroke team

B. Check and treat the glucose
C. Order an immediate CT or MRI of the brain
D. Administer tPA
E. Administer morphine
NCLEX Question
You are working in the Emergency Department when a client with a suspected
stroke arrives. Which of the following essential nursing actions should the nurse
perform? Select all that apply.
A. Activate the stroke team

B. Check and treat the glucose
C. Order an immediate CT or MRI of the brain
D. Administer tPA
E. Administer morphine
Answers: A, B, and C
According to the AHA, the immediate general assessment and stabilization
should include: assess the ABCs and vital signs, provide oxygen as needed,
obtain an IV, check glucose and treat as needed, perform an essential neurologic
screening, activation of the stroke team, order an immediate CT or MRI of the
brain, and obtain an ECG. All of these actions should be included within the first
10 minutes after arrival at the ED. The decision of whether or not to give tPA will
depend on the results of the CT scan or MRI. If the provider determines that there
is no brain hemorrhage, the team should complete the fibrinolytic checklist before
deciding whether or not to give rtPA. Administering morphine is not a priority in a
suspected stroke.
Seizures
What are Seizures?

● Seizures are not a disease in themselves
● They are a symptom of an underlying disorder.
● Epilepsy
○ “A neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of
consciousness, or convulsions, associated with abnormal electrical activity in the brain.”
○ No other underlying disorder
● Partial - limited to a specific area of the brain
● Generalized - Involves the entire brain
● Simple - No loss of consciousness.
● Complex - Impared consciousness ranging from confusion to non responsive
● Tonic/Clonic - Phases of tonic and clonic spasm

● Myoclonic - sudden, brief contractions of a muscle or group of muscles
● Absence - Loss of consciousness; staring off into space.
Treatment
● Anticonvulsants
○ Rapid acting - lorazepam
○ Long acting - phenytoin
● Very important to monitor for therapeutic levels
● Never stop taking suddenly - can cause a seizure
Seizure Precautions
NCLEX Question
Seizure precautions have been ordered for a client admitted to the psychiatric
unit. Which of the following nursing interventions is not appropriate when
initiating seizure precautions? Select all that apply.
A. Pad the side rails of the bed

B. Lower side rails while the client sleeps
C. Remove hard or sharp objects from the bed
D. Use four point restraints to prevent injury
E. Adhere a fall risk bracelet to the seizure prone client
F. Ask the family to monitor the patient 24/7.
NCLEX Question
Seizure precautions have been ordered for a client admitted to the psychiatric
unit. Which of the following nursing interventions is not appropriate when
initiating seizure precautions? Select all that apply.
A. Pad the side rails of the bed

B. Lower side rails while the client sleeps
C. Remove hard or sharp objects from the bed
D. Use four point restraints to prevent injury
E. Adhere a fall risk bracelet to the seizure prone client
F. Ask the family to monitor the patient 24/7.
Answers: B, D, + F
The correct answers are B, D, and F. Padded bed rails should remain up while the client
sleeps. Patients should be provided with a call light so that they may call for help if needed.
Four-point restraints are not appropriate for the seizing client and could result in injury. It is
not appropriate to ask the family to monitor the patient 24/7
Choice A is incorrect. When initiating seizure precautions, the nurse should ensure that the
side rails are padded.
Choice C is incorrect. All sharp objects should be removed from a client's bed when
instituting seizure precautions.
Choice E is incorrect. Patients prone to seizures should wear a fall risk bracelet to alert
members of the health care team to the client's need for increased supervision.
What is Parkinson's Disease?
● Progressive nervous system disorder.
● Caused by degeneration of dopamine neurons
Assessment findings
Interventions
● Fall risk
● No cure
● Therapy
○ PT
○ OT
SLP
● Carbidopa-levodopa.
○ Increase dopamine in the brain
What is Multiple Sclerosis?

● Autoimmune disorder
● CNS inflammation
● Damages and degrades the myelin sheath surrounding neurons
○ Demyelination
Interventions
● No cure
● Corticosteroids
○ Decrease inflammation
● Plasmapheresis
Myasthenia Gravis
● Autoimmune disorder
● Communication between nerves and muscles destroyed
● Diagnosis
○ Tensilon Test
Assessment
● Weak muscles
● Ptosis
○ Drooping eyelid
Interventions
● Cholinesterase inhibitors
● Corticosteroids
● Immunosuppressants
Day 1-
done!
See you tomorrow morning at 8:00 am!
Welcome
to Day 2!
You’ve got this!!
Gastrointestinal
Stomach
● Temporary storage for food
● Mixing and breakdown of food
● Digestion of food
Gastric ulcer
● Cause
○ H. Pylori
○ Overuse of NSAIDs
● Symptoms
○ Pain 1-2 hours after meal
○ Abdominal pain aggravated by
eating
○ Vomiting
○ Weight loss
○ Hematemesis if hemorrhage
occurs.
● Treatment
○ Treat H. Pylori infection
■ Antibiotics
○ Reduce stomach acid
■ H2-receptor blocker
■ Proton pump inhibitor
Duodenal ulcer
● Cause
○ H. Pylori
○ Overuse of NSAIDs
● Symptoms
○ Pain 2-4 hours after meals
○ Food may relieve pain
○ Weight gain
○ Melena if hemorrhage occurs.
● Treatment
○ Treat H. Pylori infection
■ Antibiotics
○ Reduce stomach acid
■ H2-receptor blocker
■ Proton pump inhibitor
Acid Reducers
H2 Receptor Blockers Proton Pump Inhibitors
famotidine, cimetidine, nizatidine omeprazole, lansoprazole, pantoprazole
● Decrease gastric acid secretion by binding ● Block gastric acid secretion by binding to
to histamine receptors on gastric parietal and inhibiting the hydrogen-potassium
cells. ATPase pump.
● Take with food. ● Take 30 minutes before first meal of the
● Take 30-90 minutes to start working. day.
GI protectant
Sucralfate
● Sticks to damaged ulcer tissue protecting it
against acid and enzymes
● Allow healing to take place
● Take on an empty stomach (2 hours after or 1
before food)
● Take at least 30 minutes apart from antacids
NCLEX Question
The patient is prescribed omeprazole. You know that the intended action of this
medication is to:
A. Enhance intestinal motility
B. Reduce esophageal pressure
C. Eradication of H. pylori growth
D. Increase stomach pH
Answer: D
Choice D is correct. Increase stomach pH. The primary action of the proton pump inhibitors (PPIs) is to
increase stomach pH or decrease the amount of acid in the stomach. The wall of the stomach produces
an enzyme that produces stomach acid. These PPI medications block those enzymes. Although the PPIs
are used in combination with antibiotics to limit H. pylori growth, it is the antibiotic that eradicates the
bacteria. The nurse should warn the patient against long-term use of PPIs since there is evidence that
this may increase the risk for osteoporosis-related fractures, hypomagnesemia, and myocardial
infarctions.
Choices A, B, and C are incorrect.
NCLEX Question
The nurse is teaching a client about the newly prescribed medication,
omeprazole. Which statement, if made by the client, would require further
teaching? Select all that apply.
A. “I should take this medication with meals and with water.”
B. “I should not take this with any other medication or food.”
C. “The medication will coat my ulcer so I can eat without pain.”
D. “I will need frequent laboratory tests while taking this medication.”
E. “I may need to take magnesium supplements while on this medication.”
Answer: A, C, + D
Choices A, C, D are correct. Esomeprazole is a proton pump inhibitor (PPI) indicated in
treating esophageal erosion, GERD, and peptic ulcer disease. The medication should be
taken half an hour before meals and with an ample amount of water. The medication does
not fortify an existing ulcer, like sucralfate. The client does not require frequent laboratory
testing while on this medication.
Choices B and E are incorrect. Correct teaching for a client receiving esomeprazole would
include taking the medication independent of any other food or medicine as it will decrease
its absorption. PPIs have the proclivity of causing hypomagnesemia, and thus, magnesium
supplementation may be recommended by the PHCP.
Ulcerative Colitis & Crohn's

Disease
Small + Large Intestines
● Small intestines
○ Absorbs nutrients!!
○ Churn and mix ingested food, making it into chyme.
○ Move the food along its entire length (into the colon)
○ Mix ingested food with mucus (making it easier to move)
○ Receive digesting enzymes from the pancreas and liver (via the pancreatic and common bile
ducts)
● Large intestines (colon)
○ Absorbing water and electrolytes
○ Producing and absorbing vitamins
○ Forming and propelling feces toward the rectum for elimination.
What is Ulcerative Colitis?

● Inflammation of the large intestines.
What is Crohn's Disease
● Inflammation AND erosion of the ileum and anywhere throughout the small
and large intestines.
Assessment
● Rebound tenderness
● Cramping
● Diarrhea
● Vomiting
● Dehydration
● Weight loss
● Rectal bleeding
● Bloody stools
● Anemia
● Fever
Treatment
● Low fiber diet
● Avoid cold or hot foods
● No smoking
● Antidiarrheals
● Antibiotics
● Steroids
● In severe cases may end up surgically removing affected portion of the
intestines.
○ Ileostomy
○ Colostomy
Appendicitis
What is appendicitis?
● Inflammation of the appendix
● Most common age = 10 years
● Most common abdominal surgery in children
● Perforation more common in children
Assessment
● Abdominal pain
○ Usually begins as generalized pain
○ Pain localizes to RLQ - McBurney’s Point
○ Rebound tenderness → indicates peritonitis
○ Sudden relief of the pain indicates perforation
● Nausea
● Vomiting
● Decreased appetite
● Fever
● Labs
○ CBC shows elevated WBC
○ Elevated CRP
● Imaging
○ CT shows inflamed appendix
Treatment
● Treatment - appendectomy
● Pre-op
○ No heat - this can aggravate inflamed appendix and cause rupture
○ Position right side, low Fowler’s for comfort
● Post-op
○ IV Fluids
○ IV antibiotics
○ Pain management
○ NPO until return of bowel sounds
○ Wound care
NCLEX Question
The patient with appendicitis is experiencing discomfort before her
appendectomy. The nurse should avoid which of the following
non-pharmaceutical therapies to relieve this discomfort?
A. Applying ice packs to the abdomen
B. Practicing breathing exercises with the patient
C. Using a heating pad
D. Encouraging rest
Answer: C
Choice C is correct. Heat should not be applied to the abdomen of patients experiencing pain from
appendicitis. Heat may cause a rupture of the appendix, which puts the client at risk for a life-threatening
condition known as peritonitis.
Choice A is incorrect. Applying ice packs to the abdomen of a patient experiencing discomfort related to
appendicitis is an appropriate non-pharmaceutical intervention.
Choice B is incorrect. Using breathing techniques to work through the pain of appendicitis is an
appropriate non-pharmaceutical intervention.
Choice D is incorrect. Encouraging plenty of rest is an excellent way to prevent and manage pain from
appendicitis.
NCLEX Question
The nurse is reassessing their client diagnosed with appendicitis. The client
expressed 8/10 pain at her last assessment, and now states they has no pain.
The nurse did not administer any pain medication. What is the critical nursing
action?
A. Document the pain score

B. Assess the client's abdomen
C. Notify the healthcare provider
D. Palpate McBurney’s point
NCLEX Question
The nurse is reassessing their client diagnosed with appendicitis. The client
expressed 8/10 pain at her last assessment, and now states they has no pain.
The nurse did not administer any pain medication. What is the critical nursing
action?
A. Document the pain score

B. Assess the client's abdomen
C. Notify the healthcare provider
D. Palpate McBurney’s point
Answer: C
A is incorrect. When a client diagnosed with appendicitis has sudden relief of pain, it is a sign of possible rupture
of the appendix. This is a surgical emergency and the client must be taken to the operating room quickly. It is not
appropriate for the nurse to document the pain score without further intervention.
B is incorrect. It is not appropriate to simply assess the client's abdomen without further intervention. Sudden
relief of pain is concerning for rupture of the appendix and requires another action.
C is correct. The nurse should immediately notify the healthcare provider of this change in the client's status. A
sudden change of 8/10 pain to no pain in the client diagnosed with appendicitis could indicate rupture, and the
healthcare provider needs to be immediately notified.
D is incorrect. The client with appendicitis will likely have pain at McBurney’s point, but this client is expressing
a sudden relief of their pain. This needs to be evaluated for possible rupture, and therefore the nurse should
immediately notify the healthcare provider.
NCSBN Client Need:
Topic: Physiological Integrity Subtopic: Physiological adaptation
Subject: Pediatric
Lesson: Endocrine
Pancreatitis
Functions of the pancreas

● Endocrine function
○ Regulates blood sugar
■ Releases insulin
■ Releases glucagon
● Exocrine function
○ Plays a big role in digestion
■ Produces and releases digestive enzymes
● Trypsin → Break down proteins
● Amylase → Breaks for carbohydrates
● Lipase → Breaks down fats
■ Enzymes released into the duodenum
What is pancreatitis?
Inflammation of the pancreas.
No. 1 cause = alcoholism
Pathophysiology
● Digestive enzymes
activate inside of the
pancreas.
● This causes
autodigestion of the
pancreas.
Assessment
● Pain ● Labs
○ Increased WBCs
○ Increases with eating due to increased enzymes
○ Increase serum lipase
● Abdominal distention
● Ascites
● Abdominal mass
● Rigid abdomen
● Cullen’s sign
● Gray Turner’s sign
● Fever
● Nausea & vomiting
● Jaundice
● Hypotension
Treatment
● NPO
● NGT to suction
● Bed rest
● Pain medications
● Steroids
● GI protectants
○ PPIs
○ H2 blockers
○ Antacids
● Monitor I&O’s
○ Fluid and electrolyte balances
● Daily weight
● NO ALCOHOL
Antacids
● Neutralize gastric acid by acting as a buffer in the acidic environment of the
stomach.
● Increases the pH in the stomach.
Examples:
Calcium carbonate (alka-seltzer, tums)
Magnesium hydroxide
Bismuth subsalicylate (Pepto-Bismol)
NCLEX Question
A patient is being evaluated in the clinic for pancreatitis. Besides an elevated
white blood cell count and serum lipase levels, which assessment finding
indicates a positive finding for pancreatitis?
A. The discoloration of the abdomen and periumbilical area
B. Overactive bowel sounds
C. Low bilirubin levels
D. Bluish discoloration of the soles of the feet
Answer: A
Choice A is correct. The discoloration of the abdomen and periumbilical area is known as Cullen’s sign
and indicates pancreatitis when it occurs in conjunction with other symptoms. Other findings include
elevated white blood cell count, bilirubin, and urinary amylase levels.
Choice B is incorrect. In pancreatitis, bowel sounds are generally diminished or absent.
Choice C is incorrect. Bilirubin levels are generally elevated in instances of pancreatitis.
Choice D is incorrect. Bluish discoloration of the feet is not associated with pancreatitis. However, bluish
discoloration of the flanks is known as Turner’s sign and is used as an indicator of pancreatitis.
Hepatitis
Functions of the liver
● Produces bile
● Produces albumin
● Produces cholesterol
● Converts glucose to glycogen for storage
● Conversion of ammonia to urea
● Metabolism of bilirubin in the breakdown of red blood cells
● Metabolism of drugs and toxins
● Production of clotting factors and regulation of blood clotting
What is hepatitis?
● Inflammation of the liver.
● Can progress to cirrhosis
● Types A, B, C, D, and E - caused by different viral infections
● Severe cases can lead to a hepatic coma.
Hepatic coma
● Protein in your diet is broken down into ammonia.
● Liver is supposed to convert the ammonia into urea.
○ Kidneys can excrete urea.
● When there is inflammation of the liver due to hepatitis, the ammonia builds
up instead of being converted to urea
● Increased ammonia levels can cause a hepatic coma.
Assessment
● Altered level of
consciousness
● Difficult to
awake
● Hyperreflexia
● Asterixis
● Fetor
Treatment
● Lactulose
○ Bacteria in the colon digest lactulose into chemicals that bind ammonia
○ The binding of ammonia prevents ammonia from moving from the colon into the blood
○ Allows the ammonia to be excreted decreasing serum ammonia
● Cleansing enema
● Decreased protein
● Monitor serum ammonia
Cirrhosis
What is Cirrhosis?
● A chronic disease of the liver marked by degeneration of cells, inflammation, and fibrous thickening
of tissue.
● Liver cells destroyed and replaced with scar tissue
● This impairs blood flow to the liver causing portal hypertension
● Causes:
○ Alcoholism
○ Hepatitis
Assessment
● Palpable, firm liver
● Abdominal pain
● Dyspepsia
● Decreased serum albumin
● Ascites
● Splenomegaly
● Increased liver enzymes
○ ALT
○ AST
● One of the major functions of the liver is the production of clotting factors.
● Liver damage = bleeding risk
○ Anemia
Treatment
● Antacids
● Vitamins
● Diuretics
● Paracentesis
● Low protein, low sodium diet
● Stricts I&Os
● Daily weights
● Bleeding precautions
● Skin care
● Be very careful with drug doses. The liver cannot metabolize as well; most doses need
to be decreased. Especially important with :
○ Narcotics
○ Acetaminophen (as a rule, avoid in liver clients)
Genitourinary
The Urinary Tract

Urinary Tract Infection (UTI)
● An infection in any part of your urinary system
○ Kidneys
■ Pyelonephritis
○ Ureters
○ Bladder
○ Urethra
● Most common = lower (bladder, urethra)
● More common in men
Assessment
Treatment
● Hydration - drink LOTS of water!
● Cranberry juice??
○ No conclusive evidence this really helps!
● Antibiotics
Kidney anatomy + physiology

● Nephron
○ Functional unit of the kidney
● Glomerulus
○ Bundle of capillaries where
the filtration occurs in the
nephron.
Functions of the kidneys
● Control acid-base balance
○ Production of bicarbonate
● Maintain electrolyte balance
● Remove toxins from the blood
○ Urea nitrogen + Creatinine
● Produce erythropoietin
● Activate vitamin D
● Regulate water balance + control blood pressure
○ RAAS system
RAAS System
Glomerulonephritis
What is Glomerulonephritis?
An acute inflammation of the kidney at the level of the nephron.
Pathophysiology
● There is an inflammatory reaction in the glomerulus of the kidney
● Antibodies lodge in the glomerulus
● This decreases the filtering capability of the kidney
● Usually caused by an infection
○ #1 = strep
Assessment
● Sore throat
● Malaise
● Headache
● Flank pain
● Hypertension
● Edema
● Decreased UOP
○ Increased urine specific gravity
○ Sediment in urine
○ Blood in the urine
● Increased BUN and Cr
Treatment
● Antibiotics for strep infection
○ Ensure client takes the entire course of antibiotics
● Strict intake and output measurement
● Rest
● Monitor BP
● Replace fluid losses
● Diet
○ Decreased protein
○ Decreased sodium
○ Increased carbs
NCLEX Question
The nurse is reviewing the assessment data for a client with acute
glomerulonephritis (AGN). Which of the following would be an expected finding?
A. Ketonuria
B. Hematuria
C. Polyuria
D. Glycosuria
Answer: B
Choice B is correct. Clinical features of acute glomerulonephritis (AGN) include proteinuria, hematuria,
periorbital edema, weight gain, high blood pressure, and decreased glomerular filtration rate (GFR).
Choices A, C, and D are incorrect. Individuals with glomerulonephritis would have oliguria and not
polyuria. This is explained because of the massive inflammation occurring in the glomerulus. Glycosuria
and ketonuria are not features of this disease; instead, these may be expected in a client with
uncontrolled blood glucose.
Additional information: AGN is a serious condition secondary to many infectious processes such as
streptococcal infections, mononucleosis, and hepatitis. Nursing care is aimed at preventing the most
common complication, which is fluid volume overload. The client may have dietary restrictions such as
fluid, sodium, and potassium. The nurse should monitor intake and output, weight, and blood pressure.
Nephrotic Syndrome
What is nephrotic syndrome?
A kidney disorder that causes your body to pass too much protein in your urine.
Causes:
● Infection: bacterial or viral

● NSAIDS
● Cancer
● Lupus
● Diabetes
● Strep
● INFLAMMATION
Pathophysiology
● An inflammatory response in the glomerulus.
● Large holes in the glomerulus form, allowing protein to leak into the urine.
● Protein leaves the blood
○ Proteinuria
○ Hypoproteinemia
● No protein in the blood? Client cannot hold onto fluid → third spacing
● Fluid is collecting in the tissues, but the circulating blood volume is low.
● RAAS kicks in to replace low blood volume --> causes retention of sodium
and water
● With no protein in the blood to hold it, furthers third spacing
Assessment
● Anasarca
● Blood clots
● High cholesterol
● Proteinuria
● Hypoalbuminemia
● Edema
● Hyperlipidemia
Treatment
● Diuretics
● ACE inhibitors
● Prednisone
● Statins
● Anticoagulation
● Dialysis
● Diet
○ High protein
○ Low sodium
Renal Failure
Causes
● Pre-renal - Blood cannot get to the kidneys
○ Hypotension
○ Hypovolemia
○ Shock
● Intra-renal - There is damage inside of the kidney
○ Glomerulonephritis
○ Nephrotics syndromes
○ Nephrotoxic drugs
■ Contrast
■ Aminoglycosides
● Post-renal - Something is blocking urine from
leaving the kidneys
○ Kidney stone
○ Tumor
○ Urethral obstruction
○ Enlarged prostate
Acute
● Acute Kidney Injury (AKI) or Acute Renal Failure (ARF)
○ Sudden
○ Happens over a few hours or a few days
○ Causes a build-up of waste products in the blood
PRE-renal INTRA-renal POST-renal
-Heart failure -Nephrotoxic drug -Kidney stone
-Glomerulonephritis -Obstruction
Assessment
● Oliguria
● Edema
● Labs
○ Increased BUN & Cr
○ Metabolic acidosis
○ Anemia
○ Hyperkalemia
○ Hyperphosphatemia
○ Hypocalcemia
● Fatigue
● Confusion
● Nausea
Chronic
● Chronic Kidney Disease (CKD)
○ Happens slowly over a long period of time
○ Damage to the kidneys accumulates over time
○ Can no longer filter waste properly
○ Waste products build up
PRE-renal INTRA-renal POST-renal
-Sepsis -Inflammatory diseases -BPD
Assessment
● Labs
○ Increased BUN & Cr
○ Metabolic acidosis
○ Hyperkalemia
○ Hyperphosphatemia
○ Hypocalcemia
● Anorexia
● Nausea & vomiting
● Fatigue
● Itchy skin
● Muscle cramps
● Osteoporosis
Treatment
● Close follow up with PCP
● Regular lab work
● Dialysis
NCLEX Question
Which assessment data should the nurse recognize as a sign of acute kidney
injury (AKI)?
A. Hypernatremia
B. Metabolic alkalosis
C. Oliguria
D. Hypokalemia
Answer: C
Choice C is correct. Oliguria (urine output less than 400 mL/24 hours) is the most common initial sign of
an AKI. It is usually seen within the first week of the injury.
Choice A is incorrect. When the kidneys are damaged, they are unable to retain sodium. Sodium levels
would be decreased (hyponatremia), not increased.
Choice B is incorrect. Metabolic acidosis, not alkalosis, is typically seen with AKI. The kidneys are unable
to excrete acids and unable to synthesize the ammonia needed to excrete hydrogen ions. Serum
bicarbonate decreases and reabsorption of bicarbonate is ineffective, resulting in acidosis.
Choice D is incorrect. Hyperkalemia, not hypokalemia, is seen with acute kidney injury. In AKI, the
kidneys cannot excrete excess potassium normally. Metabolic acidosis can also develop, causing
increased hydrogen ions into the cell, which forces additional potassium into the extracellular fluid.
Dialysis
Types
A treatment that gets rid of the bodies unwanted toxins, waste products and
excess fluids by filtering the blood.
1. Hemodialysis
2. Peritoneal Dialysis
Hemodialysis
● Done 3-4 times per week.
● Client must be anticoagulated
● Will cause rapid fluid shift (300-800
mL/min)
○ Monitor BP
○ Monitor electrolytes
○ Not all can tolerate
● Client must have a fistula
○ No BPs/sticks in the arm of the fistula
○ Palpate a thrill
○ Auscultate a bruit
Peritoneal Dialysis
● Uses the peritoneal membrane as the filter
instead of a machine
● Process:
○ Dialysate is infused into peritoneal cavity
(2,000-2,500 mLs)
○ Dwells for about 6 hours
○ Fluid is drained, taking the toxins along
with it.
● Drainage should be clear - cloudy drainage
indicates an infection.
● Ensure all of the diastylate comes off.
○ Turn side to side if decreased fluid returns.
● This is better for clients who cannot tolerate the
fluid shifts in hemodialysis
NCLEX Question
The nurse is assessing a client receiving peritoneal dialysis. Which laboratory
result should immediately be reported to the primary healthcare provider
(PHCP)?
A. WBC 19,000 mm3
B. Hemoglobin 9 mg/dL
C. Calcium 8.6 mg/dL
D. Serum pH 7.33
Answer: A
Choice A is correct. The biggest complication associated with peritoneal dialysis is peritonitis.
Manifestations associated with peritonitis include fever, abdominal rigidity, purulent effluent, and
nausea/vomiting.
Choices B, C, and D are incorrect. A client with chronic kidney disease will have anemia, hypocalcemia,
and metabolic acidosis. These are all expected findings and do not need to be reported to the PHCP. The
anemia is related to the kidneys inability to secrete erythropoietin (EPO). Hypocalcemia is linked to the
inability of the kidneys to recycle vitamin D. Finally, acidosis is consistent because of the kidney's inability
to regulate sodium bicarbonate.
Additional information: When caring for a client performing peritoneal dialysis, it is essential to
reinforce measures to reduce the risk of infection. These measures should include meticulous hand
hygiene, sterile dressing to the catheter insertion site, and appropriate cleaning of the insertion site with
antibacterial soap and water.
Break Back at….

Endocrine
Not enough steroids → Addison’s

Hormone - disease
Glucocorticoids, Too many steroids → Cushing's

disease
mineralocorticoids, and sex
hormones….
STEROIDS
Steroids
● Produced by the adrenal cortex
● Glucocorticoids
○ Affect mood
○ Cause immunosuppression
○ Breakdown fats & proteins
○ Inhibit insulin
● Mineralocorticoids - aldosterone
○ Retention of sodium and water
○ Excretion of potassium
● Sex hormones - testosterone, estrogen, progesterone
Addison’s Disease
What is Addison’s Disease
● Adrenocortical insufficiency - not enough steroids
● Decreased glucocorticoids
○ Fatigue
○ Weight loss
○ Hypoglycemia
○ Confusion
● Decreased mineralocorticoids
○ Loss of sodium and water → hyponatremic, fluid volume deficit
○ Retention of potassium → hyperkalemic
○ Hypotension
● Decreased sex hormones
Treatment
● Think SHOCK!
○ IV fluid administration
○ Increased sodium intake
● I&O
● Daily weight
● Replace steroids
○ Prednisolone
○ Fludrocortisone
NCLEX Question
A nurse knows that in the event of an Addisonian crisis, it is most appropriate to
administer which of the following medications intravenously?
a. Insulin
b. Normal saline solution
c. dextrose 5% in water
d. dextrose 5% in half-normal saline solution
Answer: B
One problem of a client in the Addisonian crisis is hyponatremia. The nurse
should, therefore, anticipate administering the standard saline solution. Glucose,
vasopressors, and hydrocortisone are also used to treat the Addisonian crisis. It
would be inappropriate to administer insulin, dextrose 5% in water, or dextrose
5% in half-normal saline solution for this client. The correct answer is option B,
while options A, C, and D are incorrect.
Cushing’s Disease
What is Cushing’s Disease?
● Excess of steroids
● Body has too much glucocorticoids, mineralocorticoids and sex hormones
○ Glucocorticoids
■ Immunosuppression
■ Hyperglycemia
■ Mood alteration
■ Fat redistribution (excess glucocorticoids cause lipolysis of extremities and lipogenesis
in the trunk)
○ Mineralocorticoids
■ Fluid retention
■ Sodium retention
■ Potassium excretion
○ Sex hormones
■ Oily skin/acne
Assessment
● Moon faced
● Truncal obesity
● Buffalo hump
● Thin extremities
● Hyperglycemia
● Immunosuppressed
● Fluid volume excess
● Weight gain
● CHF
Treatment
● Adrenalectomy
○ Remove the glands secreting the excess hormones
○ Can remove one or both
● Avoid infection
○ client is immunosuppressed
○ Hand washing
○ Limiting visitors
Hormone - Not enough ADH → DI
Antidiuretic hormone Too much ADH → SIADH
(ADH)
Antidiuretic Hormone
● Secreted from the pituitary gland
● Pituitary gland is in the brain, between your eyeballs
● Be on the lookout for these issues if a client had:
○ Craniotomy
○ Head injury
○ Sinus surgery
● Causes anti - diuresis - holding on to WATER
○ Only water is retained, so sodium!
○ Increased ADH → increased water
● Antidiuretic hormone = ADH = Vasopressin
Diabetes Insipidus
(DI)
What is Diabetes Insipidus?
● There is not enough ADH in the body
● Without ADH to tell the body to hold onto water, the kidneys produce HUGE
amounts of urine.
● This leads to fluid volume deficit
● Hypotension
● Shock
Assessment
Lab Values
● Urine = dilute
○ Decreased USG
○ Decreased urine osmolarity
● Blood = concentrated
○ Increased Serum Na
○ Increased serum osmolarity
○ Serum Hct > 40%
Treatment
● Monitor Neuro status
● Replace fluids
○ Monitory hourly UOP
○ Replace volume + MIVF
● Vasopressin
Syndrome of Inappropriate
Antidiuretic Hormone
Secretion
(SIADH)
What is SIADH?
● The body is making too much ADH
● With too much antidiuresis, the kidneys stop excreting water and HOLD ON
to it!
● Decreased UOP
● Retention of water in the intravascular space.
● ONLY water is retained…. No sodium.
○ Body remains euvolemic.
Assessment
● Weight gain
● NO peripheral edema
● Anorexia
● Nausea
● Vomiting
● Low serum sodium
○ Irritability
○ Confusion
○ Hallucinations
○ Seizures (Na < 125)
Lab values
● Urine = concentrated
○ Decreased UOP
○ Increased urine osmolality
○ Increased urine specific gravity
○ Increased urine sodium
● Blood = dilute
○ Increased blood volume
○ Decreased blood osmolality
○ Hyponatremia
○ Anemia
Treatment
● Monitor serum sodium
○ Sodium replacement
● Seizure precautions
● Fluid restriction
● Hypertonic saline
NCLEX Question
A client suddenly develops syndrome of inappropriate antidiuretic hormone
(SIADH) after undergoing cranial surgery. Which manifestations should the nurse
expect to see from the client?.
a. Edema and weight gain

b. Decreased urine production
c. Hypotension
d. A low urine specific gravity
Answers: B
A is incorrect. Because of free water retention, there is increased retention of water in the intravascular
space. But triggers the kidneys to excrete sodium, balancing the fluid status of the client. They are
euvolemic. Weight gain is seen, but peripheral edema is not. This absence of peripheral edema is a
specific finding of SIADH.
B is correct. Decreased urine production is a finding of SIADH. Because of the increase in ADH, there is
an increased retention of free water and a decrease in urine output.
C is incorrect. You would expect to see a normal blood pressure in SIADH. Only free water is retained, no
sodium, and the body remains in a euvolemic state. This means that clients with SIADH are
normotensive.
D is incorrect. A low urine specific gravity would be seen in DI, when the production of ADH is decreased
and the body secretes large amounts of dilute urine. In SIADH, the body retains free water and makes
small amounts of concentrated urine, so the specific gravity is increased.
DI vs. SIADH
DI SIADH
Urine Output High Low
Urine osmolarity & Low High

specific gravity
Serum sodium High Low

Not enough thyroid hormone →
Hormone - hypothyroidism
Thyroid hormone Too much thyroid hormone →

hyperthyroidism (Grave’s Disease)
(T3 & T4)
Thyroid hormone
● Produced by the thyroid gland
● There are two types: T3 and T4
● Thyroid hormones = energy
● They are controlled by a
negative feedback loop
● Thyroid Stimulating Hormone
(TSH) controls the release of T3
and T4
○ Low T3 and T4 cause High TSH
○ High T3 and T4 cause low TSH
Hyperthyroidism
What is hyperthyroidism?
● Also known as Graves Disease
● The body has too much thyroid hormone
● Decreased levels of TSH
● Anterior pituitary see’s low TSH and signals to the Thyroid gland to secrete
more T3 and T4
● T3 and T4 continue to be secreted despite being high
● The negative feedback loop is broken
High T4 / Low TSH

Thyroid storm
Treatment
● Antithyroid - methimazole
○ Stops the thyroid from making T3 and T4
● Iodine compounds
○ Used to decrease the size and vascularity of the
thyroid gland
● Radioactive Iodine therapy
○ Destroys thyroid cells
○ Can cause hypothyroidism
● Thyroidectomy
○ Removal of all or some of the thyroid gland
○ If all of the thyroid gland is removed, replacement of
thyroid hormone will be necessary post-op.
Hypothyroidism
What is hypothyroidism?
● The body does not have enough thyroid hormone
● Increased levels of TSH trying to signal the thyroid to make more T3 and T4
● Thyroid gland cannot secrete enough T3 and T4 despite high TSH
● T3 and T4 continue to be low
● The negative feedback loop is broken
Low T4 / High TSH

Treatment
● Levothyroxine - thyroid hormone
○ Take on an empty stomach
○ Take at the same time every day
○ Will take this forever
Not enough PTH →

Hormone - Hypoparathyroidism
Parathyroid Hormone Too much PTH →

Hyperparathyroidism
(PTH)
Parathyroid Hormone
● Secreted by the parathyroid glands
● Causes calcium to be pulled out of the
bones and into the blood.
● Causes an increase in serum calcium.
Hypoparathyroidism
What is hypoparathyroidism?
● The parathyroid glands do not
secrete enough PTH
● There are low serum calcium
levels
● Low serum calcium levels cause
high serum phosphorus levels
Assessment
Treatment
● Fix the electrolyte imbalances
○ Calcium replacement
○ Phosphorus binders
Hyperparathyroidism
What is hyperparathyroidism?
● The parathyroid glands
secrete too much PTH
● There are high serum
calcium levels
● High serum calcium levels
cause low serum
phosphorus levels
Assessment
Treatment
● Partial parathyroidectomy
○ There are 4 parathyroid glands
○ Taking out 2 can decrease PTH secretion
○ Can cause rebound hypocalcemia if decreases too much
Break Back at….

Hormone - Not enough Insulin → DM, DKA,
HHNS
Insulin Too much Insulin → Hypoglycemia
Insulin
● Produced in the pancreas
○ 𝛃-islets of Langerhan
● Acts as the ‘key’ to transport glucose
from the bloodstream to the cells
● Allows the cells to use glucose as
fuel
● Normal BG: 70-110
Diabetes Mellitus Type I
What is Diabetes Mellitus Type I?
● DMTI
● Autoimmune disease - or idiopathic
● Body has destroyed the beta cells of
the pancreas that produce insulin
● There is little or no insulin in the body
● Very high levels of glucose in the
bloodstream
● No glucose can get to the cells for
fuel
Assessment
Treatment
INSULIN
● Basal bolus system

● Long-acting agent given once per day
● Rapid-acting agent given with meals to cover the carbs eaten
● Regular insulin
○ Short acting
● NPH
○ Intermediate acting
● Glargine
○ Long acting
Insulin Peak and Onset Times

Type Generic Onset Peak Duration
Name
Rapid-Acting Insulin 15 min 30-90 min 3-5 hrs

aspart
Insulin 15 min 30-90 min 3-5 hrs

lispro
Short-Acting Regular 30-60 min 2-4 hrs 6-8 hrs
Intermediate- NPH 1-2 hrs 6-14 hrs 16-24 hrs

acting
Long-acting Glargine 1-2 hrs none 24 hrs

Insulin Storage
● Keep away from heat and direct sunlight
● Never freeze insulin
● Store in the refrigerator until ready for use
● When actively using, keep at room temperature
● At room temperature:
○ NPH: good for one month
○ Glargine: good for 28 days
○ Rapid and short acting: good for 28 days
Mixing Insulin
1. Draw up air equal to the total amount of insulin needed
2. Inject the correct amount of air into the NPH vial
3. Inject the remaining air into the regular insulin
4. Draw up the correct amount of regular insulin
5. Draw up the correct amount of NPH insulin
Clear, then cloudy (regular 1st, NPH 2nd!)
NEVER mix long-acting insulin

Insulin Administration
● Can only give Regular via IV
● All others given SubQ
● Rotate sites
● Syringes measured in units
● Never use expired or cloudy insulin
○ NPH is the only cloudy insulin
SubQ sites
Diabetic Ketoacidosis
(DKA)
What is Diabetic Ketoacidosis?
● There is no insulin to carry glucose to the cells
● Glucose builds up in the blood (High BG)
● Blood becomes hypertonic, causing fluid to shift into the vascular space.
● Kidneys work to filter this excess fluid and glucose - polyuria
● Cells are not receiving any fluid or glucose - they are starving - polydipsia &
polyphagia
● Because cells don’t have any glucose for energy, break down proteins and fat
● This produces ketones - which are an acid
● Causes a metabolic acidosis
○ Kussmaul respirations - to blow off CO2 to compensate
○ High serum potassium
Assessment
Treatment
● Labs
○ Hourly BG and serum potassium
○ ABGs - evaluate the metabolic acidosis and look for resolution
● Fluids
○ Monitor output and prevent shock
○ NS used to start
○ When BG lowers to 250-300, D5W added to solution to prevent hypoglycemia
■ Blood sugar should be lowered slowly
■ Rapid drop will cause a shift of fluid into the cells and cerebral edema
● Insulin
○ Decrease the blood sugar
○ Drive potassium back into the cell
Diabetes Mellitus Type II

What is Diabetes Mellitus Type II?
● There is either not enough insulin,
insulin resistance, or bad insulin
● Commonly found with clients who
are overweight.
● Their body can’t make enough
insulin to keep up with the glucose.
● The increased glucose in the blood
suppresses the immune system,
causes increased bacteria in the
blood, and decreases circulation.
● This is what causes long term
damage:
○ Poor wound healing
○ Frequent infections
○ Vision problems
○ Kidney problems
Treatment
DIET
ORAL AGENTS
● Low carb - complex carbs
● Work to decrease the amount
● Proteins & veggies
of circulating glucose
EXERCISE ● Improves how the body
produces insulin and uses
● Eat before exercising insulin
● Exercise when blood sugar is ● Metformin
at its highest
● Establish a routine INSULIN
Hypoglycemia
What is Hypoglycemia?
● When there is not enough glucose in the bloodstream
● BG <70
● Causes
○ Not enough food
○ Too much insulin
○ Too much exercise
Assessment
● Cold
● Clammy
● Confused
● Shakey
● Nervous
● Nausea
● Headache
● Hungry
Treatment
1. Have a snack - about 15 grams of carbs
a. 4-6 oz of soda/juice/milk
b. 8-10 pieces of candy
2. Wait 15 minutes, and check BG again
3. If still <70, eat another 15 grams of carbs
4. After the BG rises, eat a snack with complex carb/protein to help keep the BG up
a. Crackers with peanut butter
What if the client is unconscious?!

If IV access → push D50W
If no IV → IM Glucagon (catabolic hormone, raises concentration of glucose in the bloodstream)

Break Back at….
Hematology &
Infectious Disease
Anatomy + Physiology
Hematology
Bone Marrow
● Produces blood cells
○ Stem cells
○ Erythrocytes
○ Leukocytes
○ Thrombocytes
● Immune response
○
Blood components
Accessory organs
● Kidneys
○ Erythropoietin
■ Stimulates production of erythrocytes
● Spleen
○ Thrombopoietin
■ Controls thrombocyte production
○ 20% of thromobytes stored in the spleen.
○ Breaks down old erythrocytes
● Liver
○ Clotting factors
Blood clotting
● Hemostasis
○ Prevent blood loss
○ Maintain perfusion
● Triggered by platelet aggregation
● Two pathways
○ Intrinsic
■ Triggered by changes in the blood
○ Extrinsic
■ Triggered by something occurring outside the blood vessels
● End result of coagulation = a blood clot….. Hemostasis!
Polycythemia Vera
What is polycythemia vera?

● Loss of cellular regulation
● Excessive number of erythrocytes, leukocytes, and thrombocytes
● This causes the blood to become hyper viscous
○ Hemoglobin > 18 in men and >16.5 in women
○ Hematocrit > 55%
● The thicker the blood, the more problems with perfusion the patient can
have.
Assessment
● Skin
○ Dark purple, cyanotic appearance
● CV
○ Distended veins
■ Causes intense itching
○ Hypertension
○ Thrombosis
○ Poor gas exchange
■ Hypoxia
Treatment
● Apheresis
○ Withdrawal of whole blood
○ Removal of the excessive components (erythrocytes)
○ Reinfusion of the plasma back to the patient
● Anticoagulation
● Hydration
Patient education
Drink at least 3 liters of liquids each day.
Avoid tight or constrictive clothing.
Wear gloves when outdoors in temperatures lower than 50°F (10°C).
Contact your primary health care provider at the first sign of infection.
Wear support hose or stockings while you are awake and up.
Elevate your feet whenever you are seated.
Stop activity at the first sign of chest pain.
Use an electric shaver.
Use a soft-bristle toothbrush to brush your teeth.
Do not floss between your teeth.
If you are a smoker, strongly consider smoking cessation.
NCLEX Question
Which priority intervention does the nurse teach the client with polycythemia
vera to prevent harm related to injury due to decreased platelet functionality?
A. Wear gloves when outside in the cold.

B. Drink 3-4 L of liquid each day.
C. Use an electric shaver
D. Elevate your feet when sitting down.
Answer: C
A is incorrect. Wear gloves when outside in the cold.” is appropriate education for this
patient, but not related to the risk for injury due to decreased platelet function. This
educational point is related to the poor perfusion due to hyperviscous blood.
B is incorrect. “Drink 3-4 L of liquid each day” is appropriate education for this patient,
but not related to the risk for injury due to decreased platelet function. This
C is correct. “Use an electric shaver” is an educational point that will help prevent
bleeding and decrease the risk of injury due to poor platelet function.
D is incorrect. “Elevate your feet when sitting down.” s appropriate education for this
patient, but not related to the risk for injury due to decreased platelet function. This
Anemia
What is anemia?
● Reduction in the number of erythrocytes
● Can occur with many different disease processes
● Several types and causes
Iron deficiency anemia

Inadequate iron intake caused by:
● Iron-deficient diet
● Chronic alcoholism
● Malabsorption syndromes
● Partial gastrectomy
● Rapid metabolic (anabolic) activity caused by:
○ Pregnancy
○ Adolescence
○ Infection
● Most common!
Vitamin B12 deficiency anemia
Dietary deficiency
Failure to absorb vitamin B12 from intestinal tract as a result of:
• Partial gastrectomy
• Pernicious anemia
• Malabsorption syndromes
Aplastic anemia
Body stops producing enough new blood cells.
Causes include exposure to myelotoxic agents:
• Radiation
• Benzene
• Chloramphenicol
• Alkylating agents
• Antimetabolites
• Sulfonamides
• Insecticides
Assessment findings
● CV
○ Tachycardia
● Skin
○ Pallor
○ Orthostatic hypotension
○ Cool
● Respiratory ○ Mottled
○ Dyspnea on exertion ○ Delayed capillary refill
○ Decreased SpO2 ○ Unable to tolerate the cold
● Neuro
○ Fatigue
○ Increased need for sleep
Treatment
● Depends on the specific type of anemia
○ Iron deficiency anemia →
■ Increased iron in the diet and iron supplements.
○ Vitamin B12 deficiency anemia →
■ Increased B12 in diet and supplements.
○ Aplastic anemia →
■ Depends on cause
■ Discontinue causative drug/exposure if possible
■ Blood transfusions
Sickle cell anemia
Sickle Cell Anemia

A disorder that causes the red blood cells to ‘sickle’ and break down.
Autosomal recessive
Pathophysiology
● Autosomal recessive
● Those with the trait have ‘sickled’
RBCs
● The sickled cells are not able to
carry oxygen like they should
○ Decreased perfusion
● Due to their shape, they can get
caught in vessels and cause
obstruction
Sickle Cell Crisis

● The decreased blood flow to the tissues leads to hypoxia, ischemia, and
infarction.
● There is severe joint pain
● Sequestration
○ Blood pools
○ Often in the spleen
○ Splenomegaly and tenderness
● Acute exacerbation can be caused by hypoxia, exercise, high altitude (due to
low oxygen), and fever.
Assessment
● Pallor
● Pain
● Fatigue
● Arthralgia
● Chest pain
● Respiratory distress
Treatment
● IV Fluids
○ This helps dilute the blood so that the sickled cells are not so concentrated
○ Provides hydration
● Blood transfusion
○ Provides normal RBCs
○ Helps optimize oxygenation and better perfusion
● Oxygen
○ Increase oxygen to the tissues if the client is hypoxic
● Medications
○ Pain management - Analgesics often necessary
○ Hydroxyurea
■ Increases production of fetal hemoglobin to reduce crises
NCLEX Question
You are providing education to your 8 year old client diagnosed with sickle cell
anemia. He has had three crisis events this year. Which of the following points do
you enforce with him and his parents to help prevent more sickle cell crises?
a. Drink lots of water

b. Perform vigorous exercise for 60 minutes a day
c. Avoid flying on airplanes
d. Call the PCP if he becomes febrile.
e. Encourage a diet high in calcium.
Answer: A, C, and D
A is correct. Hydration is an essential component of preventing a sickle cell crisis, so this is very important education. By
drinking lots of water, the boy will increase the volume in his vascular space with fluid, essentially “thinning out” the
sickled cells. In other words, they will not be as concentrated anymore. This will help to prevent the sickled cells from
snagging on vessels, creating occlusions, and causing a crisis.
B is incorrect. While promoting a healthy lifestyle is always important, vigorous exercise is a specific trigger for a sickle
cell crisis. This is because during vigorous exercise the tissues have a high demand for oxygen and the sickled cells are
unable to deliver a sufficient amount. This results in a crisis. So for this client, 60 minutes of vigorous exercise every day
would not be a good recommendation.
C is correct. Avoiding flying on airplanes is good education. In airplanes, you are at a very high altitude where there is
much less oxygen. This can be a trigger for a sickle cell crisis because it leads to a high oxygen demand state.
D is correct. It is important for the parents to know to call the child’s primary care doctor if he is ill with a fever. Because
the body demands more oxygen when it is febrile, fevers are a trigger for sickle cell crises, and must be treated promptly.
E is incorrect. Encouraging a high calcium diet will not prevent the patient from having sickle cell crises.
NCSBN Client Need:

Reference: Reference: Hockenberry, M., Wilson, D. & Rodgers, C. (2017). Wong’s essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited.
Subject: Pediatrics
Lesson: Hematology
Disseminated Intravascular
Coagulation
(DIC)
What is DIC?
A serious disorder in which the proteins that control blood clotting become
overactive.
Triggers
● Blood transfusion
● Cancer
● Pancreatitis
● Liver disease
● Severe tissue injury
○ Burns
○ Head injury
● Pregnancy complication
Assessment
Clotting → Where the clot goes
Bleeding
Ecchymosis ● Lungs/Heart
Hematomas ○
○
Chest pain
Dyspnea
Hemoptysis ○ SOB
Melena ● Legs
Pain
Pallor ○
○ Redness
Hematuria ○ Warmth
○ Swelling
● Brain
○ Headache
○ Speech changes
○ Paralysis
○ Dizziness
Treatment
● Determine underlying cause and TREAT
● Administer clotting factors
● Administer platelets
● Bleeding precautions
NCLEX Question
The nurse in the Intensive Care Unit notes bleeding from the client’s transparent
dressing over their peripheral intravenous site, gum bleeding, and frank blood in
the urine. The client was originally admitted for Sepsis. What should be the
nurses immediate next action?
a. Assess the client’s hemoglobin and hematocrit level

b. Check the client’s oxygen saturation.
c. Apply pressure to the intravenous site.
d. Call the physician
Answer: D
Choice D is correct. The client is manifesting signs of Disseminated Intravascular Coagulation (DIC). This is a critical complication that often
happens in the intensive care unit and usually is secondary to other serious etiologies such as Sepsis. In this condition, the clotting system is
activated significantly and leads to the consumption of platelets and clotting factors. DIC can manifest with either bleeding or clotting
complications. Thrombocytopenia (low platelet count), coagulopathy (increased prothrombin time, increased partial thromboplastin time,
decreased fibrinogen), and hemolysis are hallmarks of DIC. In the absence of any significant bleeding, transfusing platelets or clotting factors may
fuel the thrombotic process in DIC. Therefore, Platelets, cryoprecipitate, and Fresh Frozen Plasma are not routinely injected in DIC unless there is
significant bleeding. The client is bleeding from multiple sites. The nurse must call the physician first to initiate medical interventions, which may
include ordering labs to confirm DIC, transfusing platelets, or infusing clotting factors.
Choice A is incorrect. DIC is a consumption coagulopathy and also causes intravascular hemolysis. Intravascular small clots (microthrombi) form
due to activation of the coagulation pathway in DIC. Red blood cells may rub against these thrombi leading to hemolysis. Fragmented red blood
cells (schistocytes) can be seen in DIC due to this hemolysis. Hemolysis causes a drop in hemoglobin and hematocrit (Anemia). The nurse should
undoubtedly check the client's Hemoglobin and Hematocrit levels; however, the nurse needs to notify the physician right away since the client is
showing bleeding signs of DIC.
Choice B is incorrect. Assessing the client’s oxygen saturation may also be performed later. The client is not in apparent respiratory distress based
on the information presented. Hypoxia is not the cause of his bleeding complications. DIC should be suspected in this bleeding, septic clientand the
nurse must notify the physician immediately since urgent intervention is needed
Choice C is incorrect. The client is bleeding from multiple sites. The application of pressure to the intravenous site alone will not help stop the
bleeding from other websites. DIC is a consumption coagulopathy. All the clotting factors and platelets are being used up in the clotting process.
Therefore, the bleeding complications of DIC would necessitate platelets and clotting factor infusion.
The Immune System
Definitions
● Immunity
○ “Protection from illness or disease maintained by the body’s physiological defense
mechanisms”
● Inflammation
○ “Normal tissue response to cellular injury, allergy, or invasion by pathogens”
○ Nonspecific
● Infection
○ “The invasion of pathogens into the body that multiply and cause disease or illness”
○ Trigger inflammation
Antigens vs. Antibodies
Infections
● Communicable ● Healthcare Acquired Infections (HAIs)
○ Transmitted from person to person
○ CAUTIs
■ Influenza
○ CLABSIs
■ Pertussis
○ SSIs
■ Mumps
■ Rhinovirus
■ Adenovirus
■ Meningitis
■ Streptococcus Aureus
● Non-communicable
○ NOT transmitted from person to person
■ Peritonitis
■ Endocarditis
● Infections requiring contact precautions:
○ MRSA
○ VRE
○ Noroviruses
○ Rotavirus
○ Conjunctivitis
○ Diphtheria (cutaneous)
○ Herpes Simplex virus
○ Human Metapneumovirus
○ Pediculosis (lice)
○ Scabies
○ Poliomyelitis
○ Staphylococcus aureus
● Infections requiring droplet precautions:

○ Influenza
○ Pertussis
○ Mumps
○ Rhinovirus
○ Adenovirus
○ Meningitis
○ Streptococcus Aureus
○ Rubella
○ Haemophilus influenzae type B
■ Epiglottitis
○ Parvovirus
○ Diphtheria (pharyngeal)
● Infections requiring airborne precautions:
○ Tuberculosis
○ Rubeola virus (Measles)
○ Varicella virus (Chickenpox)
○ Varicella zoster
○ SARS
○ Smallpox
Sepsis
What is sepsis?
● A systemic inflammatory reaction to an infection.
Pathophysiology
Assessment
● Elevated lactic acid
○ Indicates body has switched to anaerobic metabolism
○ Tissues are not getting sufficient oxygen
● Metabolic acidosis
● Leukocytosis
● Hypotension
● Tachypnea
● Tachycardia
● Febrile
Treatment
● Blood cultures first
● Broad spectrum IV abx within one hour
● IV fluids
● Vasopressors
Musculoskeletal
Fractures
Neurovascular Assessment - The 5-P’s
Pain
Pulse
Pallor
Paresthesia
Paralysis
Treatment
● Pain management
● RICE
○ Rest, Ice, Compression, Elevation
● Immobilization
○ Cast
○ Splint
○ Brace
○ Monitor the casted extremity closely for perfusion!!
● Traction
○ Used temporarily for proper alignment and healing
Traction
T - Temperature - Monitor the temperature of the extremity.
R - Ropes - The ropes should be hanging freely
A - Alignment - Ensure proper alignment of the extremity.
C - Circulation - Circulation checks on extremity are #1! The 6 P’s!
T - Tension - No tension on the skin. HIGH RISK FOR SKIN BREAKDOWN!!
I - Intake - Monitor I&O’s
O - Overhead trapeze - Bar overhead to help with range of motion.
N - NO weights on the floor! - DON’T release the traction!

Compartment syndrome
What is Compartment Syndrome?
● There is increased pressure within a
confined space
○ Limbs
■ Especially in a cast!
○ Abdomen
● This increased pressure compromises
circulation
● Without circulation, the distal tissue
becomes ischemic
● Tissue and nerve damage occurs
Assessment
● Extremely painful
● Limb feels tight
● Swelling
● Numbness
● Tingling
● Paralysis
● diminished or absent pulses
● Decreased sensation
Treatment
● FASCIOTOMY
○ Must relieve the pressure in the compartment
○ Cut open the compartment
Rhabdomyolysis
What is Rhabdomyolysis?
● There is injury to the skeletal muscle
○ Burns
○ Trauma
○ Compartment syndrome
● Muscles release their intracellular contents into the blood
○ Myoglobin
○ Creatinine Kinase
○ Potassium
○ Phosphorus
● These substances become toxic in circulation
● Major kidney damage as the nephrons try to filter the toxins out
Treatment
● Fluids
○ NS
○ Hydration and flushing the kidneys
● Diuretics
○ Decreased swelling
○ Increase UOP
○ Flush out toxins
● Dialysis
○ If K too high or kidneys unable to clear the toxins on their own
● Bedrest
● Monitor electrolytes and CK
○ Worried about high K?? → TELEMETRY!
NCLEX Question
A client that has sustained a sports injury has just finished an arthroscopy on his
left knee. The nurse caring for him should FIRST assess the client for which of the
following factors?
a. Skin and wound integrity

b. Mobility assessment
c. Vascular and skin assessments
d. Circulatory and neurologic assessments
Answer: D
The nurse should always focus on assessing the client’s; neurological and
circulatory status following an arthroscopic procedure. The swelling of the
extremity can impair the neurologic and circulatory function of the leg. The nurse
can address the other concerns of skin integrity, mobility, and pain once
neurologic and circulatory integrity is established.
Fat embolism
Symptoms:
▪ Hypoxia
▪ Dyspnea
▪ Tachypnea
▪ Confusion
▪ Altered level of consciousness
▪ Petechial rash (does not always
occur)
Associated with orthopedic fractures

such as long bone and pelvic fractures.
Assistive Devices
● Walker
● Cane
● Wheelchair
● Crutches
Walker
● Stand in the center of the walker
● Slide walker forward 6-8 inches
● Keep all 4 feet of walker on ground
● Step forward with affected side
○ Keep weight on the walker and unaffected leg
● Bring unaffected leg up to walker
Crutches: Fit
● Don’t rest on armpits
● Use shoulders and arms for strength
● Slight bend through the elbows
Three-Point Gait
● For partial weight bearing
● Crutches are advanced with
the affected leg
● Unaffected leg brought
forward
Swing-Through Gait
● For non-weight bearing clients
● Stand on the unaffected leg
● Move both crutches forward
about a foot
● Brace the hand grips for support
● Swing both legs through the
crutches
Cane
● Cane goes on the unaffected side
● Slight bend at the elbow
● Cane moves forward 6-10 inches
● Affected leg moves forward with
cane
● Unaffected leg then moves past
the cane
Break! Back at…

Integumentary
Anatomy of the skin
Functions of the skin

● Epidermis
○ Protection from injury
○ Inhibits proliferation of microorganisms
○ Prevents dehydration and electrolyte loss
○ Sweat glands allow for temperature regulation, dissipation of heat
○ Transmits tactile stimulation through neuroreceptors
○ Synthesizes vitamin D
● Dermis
○ Cells for wound healing
○ Nerve receptors - signal skin injury and inflammation
○ Responds to inflammation
■ Lymphatic + vascular tissue

● Hypodermis
○ Absorbs mechanical shock - protects from injury
○ Temperature regulation
■ Fat cells insulate and retain body heat
Terminology
● Lesions → “area of tissue that has
suffered damage”
○ Primary → direct result of a disease
process
○ Secondary → develop as a
consequence of the client’s activities
● Pruritus
○ Itching
● Urticaria
○ Hives
● Lichenified
○ Thickened
Terms to describe lesions

● Annular → ringlike with raised borders around flat centers of normal skin
● Circinate → circular
● Circumscribed → well defined, sharp borders
● Clustered → several lesions grouped together
● Diffuse →widespread
● Linear → occurs in a straight line
● Macular → flat
● Papular → raised
Pressure
Injuries
Risk factors
● Lack of mobility
● Exposure to excessive moisture
○ Urinary incontinence
○ Fecal incontinence
● Undernourishment
● Aging skin
Stage 1
Stage 2
Stage 3
Stage 4
Unstageable
Determine risk
a. Use a reliable scale (e.g., Braden Scale) to assess risk, and assess entire skin daily.
b. Use a proven skin care bundle so that all health care professionals are following
consistent interventions.
c. Ensure that a nutrition consultation takes place.
d. Ensure that fluid intake is 2000 to 3000 mL/day.
e. Help the patient consume the determined amount of protein and calories.
f. Monitor changes in weight, skin turgor, urine output, renal function, serum sodium,
and calculated serum osmolality.
g. Document interventions thoroughly, and communicate with the interprofessional
team regularly to promote continuity of care.
Ways to reduce pressure
a. Do not keep the head of the bed elevated above 30 degrees to prevent shearing.
b. When positioning a client on their side, position at a 30-degree tilt (avoiding 90-degree positions).
c. Examine the source of pressure, and determine how to reduce it.
d. Help clients in chairs or wheelchairs to stand and march in place, five steps per hour (if they are able).
e. Use pressure-offloading devices or foam dressings for bony prominences (e.g., float the heels off of a
sturdy pillow.
f. Use devices such as air-fluidized beds or surfaces and powered mattress overlays to manage the
microclimate (the area between the patient’s skin and the support surface).
g. Refrain from using donut-shaped pillows; these can damage capillary beds and increase tissue necrosis.
h. For patients who cannot stand or turn themselves, turn and reposition a minimum of every 2 hours or as
needs are assessed.
Burns
1st degree
● Most superficial burn
● The skin remains intact; no break in integrity of epidermis
● Redness (erythema)
● No blisters
● Can be painful to the touch
Rule of 9’s
Rule of 9’s Worksheet

Complications of Burn Injuries
Hypovolemic Shock
● Increase in capillary permeability
● Third spacing occurs
○ Plasma moves from the intravascular space, to the interstitial space
○ Sodium
○ Albumin
● Decreased intravascular volume = decreased BP = hypovolemia
● Cardiovascular system recognizes hypovolemia - increases HR to
compensate
○ Increased HR
○ Decreased cardiac output
○ Decreased blood pressure
● Hypovolemic shock leads to decreased perfusion of kidneys and renal
damage
Hyperkalemia
● Most potassium is stored in the cells
● Injury causes lysis of cells, which then release potassium into bloodstream
● Causes hyperkalemia
● K >5.5
● Signs and symptoms:
○ Muscle weakness
○ Cramps
○ Nausea
○ Chest pain
○ Arrhythmias
○ Tall, peaked T-waves
Hyponatremia
● Water follows sodium
● Sodium is leaving the intravascular space and going to the interstitial space
● Due to increased capillary membrane permeability
● Water follows this sodium and the client becomes hyponatremic
● Na < 135
● Signs and symptoms:
○ Headache
○ Confusion
○ Restlessness
○ Irritability
○ Seizures
○ Coma
Emergency Management
● Begins with the burn injury and lasts until the capillary membrane
permeability has been restored
● Usually 24-48 hours
● Focus is on fluid replacement
● client is at risk for:
○ Hypovolemic shock
○ Respiratory distress
○ Compartment syndrome
Fluid Replacement
● Crucial in the first 24 hours
● Due to the increase in capillary permeability, this is when the client is losing
large volumes of fluid and is at risk for hypovolemic shock.
● Fluids:
○ Lactated Ringers
■ Expands the intravascular volume
○ Colloids
■ Albumin
● Helps pull fluids back into the intravascular system
● Monitor urine output
● Fluids are titrated to ensure adequate UOP (30cc/hr)
● Correction of imbalances
○ Sodium? Potassium?
Parkland Burn Formula
worksheet
Break
Back at….
Part III -
Specialties
Mental Health
Anxiety
What is anxiety?
● The body’s natural response to stress
● A feeling of fear, worry, and nervousness about what’s to come.
● Can be normal!!
● Concerning if it is chronic and in response to normal life activities.
Therapeutic Management
● Address any physical symptoms
● Ensure they are in a safe environment
○ Reorient the client
○ Decrease stimuli
○ Calm environment
○ Monitor for self-harm
● Therapeutic communication
○ Establish trust/rapport
○ Rationalize their thoughts - be logical.
○ Encourage expression of thoughts and help problem solve
○ Help restructure their thoughts
○ Determine what triggers the anxiety
Depression
What is Depression?
● “The feeling of severe despondency and dejection”
● A state of low mood
● Aversion to activity
● Affects their thoughts, behaviors, and feelings.
Therapeutic management
● Physiological needs
○ Nutrition/hydration
○ Sleep
● Safe environment - assess risk for self harm
○ One to one observation
○ Remove potentially harmful items
● Therapy
○ Express feelings
○ Validate their frustration and sadness
○ Get moving!
○ ADLs
Bipolar Disorder
What is Bipolar Disorder?

● A mood disorder where there is difficulty regulating extreme emotions.
● There are periods of mania, periods of depression, and the inability to
self-regulate these emotions.
○ Mania: “A mood disorder marked by hyperactive wildly optimistic state”
○ Depression: “The feeling of severe despondency and dejection”
○ Provide high-calorie, finger food they can eat on the go
● Safe environment
○ Calm, controlled, focused interactions
■ Don’t argue while in a manic state
■ Protect their privacy
○ Appropriate clothing
● Therapeutic Communication
○ Set boundaries
● Medications
○ Antipsychotics
○ Mood stabilizers
Schizophrenia
What is Schizophrenia?
● A long-term mental disorder involving a breakdown in the relation between
thought, emotion, and behavior.
● There is faulty perception, inappropriate actions and feelings, withdrawal
from reality and personal relationships into fantasy and delusion, and a
sense of mental fragmentation
Assessment Findings
● Delusions
○ “False belief firmly held to be true despite rational argument”
■ Persecution
■ Jealousy
■ Grandeur
● Hallucinations
○ “a sensory experience of something that does not exist outside the mind”
■ Auditory
■ Olfactory
■ Tactile
■ Visual
■ Gustatory
● Provide a safe environment
○ Decreation stimulation
○ Don’t touch them when experiencing a hallucination
○ Auditory hallucinations
■ Are they telling them to do something?
○ Ask about the delusion to understand what they are experiencing
○ Do not argue about the delusion or hallucination
○ Stay focused on reality
○ Set limits
● PRN medications
○ Haloperidol
NCLEX Question
The nurse in the psychiatric unit notes that a client with paranoid schizophrenia is
yelling and blocking the television. Other psychiatric clients around him are
getting angry. What is the most appropriate action of the nurse?
a. Restrain the client

b. Escort the other clients from the day room
c. Give Haloperidol IM
d. Approach the client calmly accompanied by two other staff
NCLEX Question
The nurse in the psychiatric unit notes that a client with paranoid schizophrenia is
yelling and blocking the television. Other psychiatric clients around him are
getting angry. What is the most appropriate action of the nurse?
a. Restrain the client

b. Escort the other clients from the day room
c. Give Haloperidol IM
d. Approach the client calmly accompanied by two other staff
Answer: D
A is incorrect. Restraining the client should be the last approach for the nurse. The
first intervention should be to talk to the client to remove him from the day room.
B is incorrect. The nurse should not try to remove the other clients from the room. The
nurse should first remove the client from the place.
C is incorrect. An IM injection of Haldol will take 30 minutes to become active. The

nurse needs to remove the client from the day before the situation escalates.
D is correct. The first intervention is to approach the client calmly and attempt to
remove him from the day room. Staff members should not contact the agitated client
alone but should be accompanied by other personnel.
Anorexia Nervosa
Assessment Findings
● Low body temperature
● Bradycardia
● Hypotension
● Cyanosis
● Electrolyte abnormalities
● Hormonal imbalances
● Sleep disturbances
● Bone degeneration→ Osteoporosis
● Amenorrhea
● Lanugo
● GI upset
○ Body temperature
○ HR
○ Electrolyte imbalances
● Ensure safety
○ SI
○ Self harm
○ Establish rapport
○ Validate their feelings
○ No judgement
○ Explore triggers
■ Help make a plan to avoid
■ What to do when triggered
Bulimia Nervosa
Assessment Findings
● Labile mood
● Helplessness
● Purging via vomiting
○ Esophageal varices
○ Tooth enamel break down
○ Russell’s Sign
○ Electrolyte imbalances
○ Esophageal varices
● Provide a safe environment
○ Monitor for self-harm and suicidal ideations
○ May not use the bathroom for 90 minutes after meals
○ Must be observed to prevent purging
● Therapeutic communication
○ Validate their feelings
○ Help identify triggers and avoid
NCLEX Question
A nurse is assigned to care for a client with bulimia nervosa. Which intervention
should the nurse apply following the client's meals?
a. Instruct the client to get some exercise or go for a walk after meals
b. Restrict client from going to the bathroom for 90 minutes
c. Ask the client to lie down for 2 hours after eating
d. Encourage client to start an intense exercise program
Answer: B
The nurse should observe the client while eating and prevent the client from
using the bathroom for 90 minutes after meals to break the purging cycle.
Exercise is not encouraged until the client has shown adequate weight gain. Until
then, training should be done in moderation. There is no need for the client to lie
down after meals. The correct answer is option B, while options A, C, and D are
incorrect.
Therapeutic Communication
Open-ended questions
● Provides the client with an opportunity to express their thoughts
● Encourages communication
● Focuses on client centered responses
● Allows the client to be in charge of the direction of the conversation.

Never dismiss a client's feelings
● Important to make sure the client knows they are heard.
● Their feelings should be validated.
● “You have nothing to worry about”

● “It will all be okay”
● “Others have it worse off than you do”
● “I’ll just give you some medication so you can relax”
Never give false reassurance

● These are promises you can’t always keep
● Don’t give you any chance to explore the client's feelings.
● “Nothing bad can happen to you here”

● “It will all be alright”
● “You don’t need to worry you’re safe here”
Therapeutic Silence
● Effective for clients in the acute phase of severe depression
● Makes no demands of them
● Simply be with them
Never ask WHY

● Why statements are not therapeutic.
● This points the finger at the client and makes them feel as if it is their fault
they are having these feelings.
● Asking why someone feels the way they do invalidates them
● It will not promote the open and honest communication that is necessary for
a therapeutic environment.
NCLEX Question
A client is scheduled for hip replacement surgery. they expresses anxiety to the
nurse about the upcoming surgery. Which response by the nurse is most
therapeutic?
A. “Everyone is nervous before any surgery. What you feel is completely

normal.”
B. “Here’s what’s going to happen to you during the procedure. I will explain to
you in detail.”
C. “Can you tell me what you have been told about the surgery?”
D. “Let me tell you about the care you will receive and the pain you should
anticipate after the surgery.”
Answer: C
Rationale: Open-ended questions that facilitate further discussion is most
therapeutic in this situation. Option C provides the client with an opportunity to
express their thoughts further and would give the nurse a baseline of the client's
knowledge and readiness for the surgery; thus, the correct answer. This way, the
nurse can come up with appropriate explanations around what the client already
knows and by filling in facts. Options A, B, and D will only increase the client's
level of anxiety and are, therefore, incorrect.
Lunch
Break! Back at….
Obstetrics
Presumptive signs of pregnancy
● Amenorrhea
● Discomforts of pregnancy
○ Nausea, vomiting
○ Frequency, urgency
○ Enlarged, tender breasts
○ Fatigue
● Quickening
Probable signs of pregnancy

● Positive pregnancy test
● Goodell sign
● Hegar sign
● Chadwick sign
● Chloasma
● Linea nigra
● Braxton-hicks’
● Ballottement
Positive signs of pregnancy
● Audible fetal heartbeat by doppler
○ 10-12 weeks
● Fetal movement detected by clinician
○ 20 weeks
● Visualization of the fetus by ultrasound
Antepartum
Testing
Routine exams done for everyone

● Blood type/Rh factor
● STI testing
● Glucose challenge
● Urinalysis
● Ultrasound
● Nonstress test (NST)
● Group B Strep
● Kick counts
Blood type and Rh Factor
● Important to know the mother's blood type and if they is Rh positive or
negative.
● If the mother is Rh negative, and the baby is Rh positive, this is considered a
‘set up’ and puts the infant at risk for erythroblastosis fetalis.
● Further testing needed if this is the case - after the baby is born.
○ Direct Coombs test
■ Performed on the newborn's blood sample
○ Indirect Coombs test
■ Performed on the mother’s blood sample
● Treatment = Rhogam
Glucose Challenge 3 hour Glucose Tolerance Test
Oral Glucose Tolerance Test
● Done if the 1 hour test is failed or there
● Done at 28 weeks are other risk factors.
● Mother drinks 50 grams of ● It is done fasting; mothers must not eat or
glucose in an oral solution drink for 8 hours prior to the test.
● 1 hour later her blood sugar ● A fasting sugar is checked
● The mother drinks 100 grams of oral
is checked.
glucose.
● If the BG is greater than
● Her BG is rechecked a 1 hour, 2 hours,
140, the 3 hours glucose
and 3 hours.
test is performed.
● A sugar greater than 140 indicates
gestational diabetes.
Nonstress Test (NST)

● This test assesses fetal well-being and oxygenation of the placenta
● Evaluates if there are changes in the fetal heart rate with movement
○ Increase in fetal heart rate with movement = acceleration = good
○ Decrease in fetal heart rate with movement = deceleration = bad
■ This is a sign that the fetus will not tolerate labor.
● Results
○ Reactive
■ There are at least two accelerations of 15 beats per minutes for 15 seconds in a 20
minute period.
○ Non-Reactive
■ There are NOT at least two accelerations of 15 beats per minutes for 15 seconds in a
20 minute period.
● Further testing required if result is non-reactive
Contraction Stress Test
● Preformed when the non-stress test is non-reactive.
● Pitocin is administered to induce contractions and the baby is monitored to
evaluate their response to contractions.
● Checking to see if the baby will tolerate labor, or show signs of stress.
● Results
○ Negative
■ Normal
■ The baby did not have decelerations in response to contractives
○ Positive
■ Bad
■ The baby had decelerations indicating distress in response to contractions.
NCLEX Question
Which of the following are required for a nonstress test to be considered reactive? Select all that apply.
a. Two increases in the fetal heart rate of 15 beats per minute

b. Two decreases in the fetal heart rate of 15 beats per minute
c. Two increases in the fetal heart rate for 15 seconds
d. Two decreases in the fetal heart rate for 15 seconds
e. Moderate variability
f. Absent variability
Answer: A and C
A is correct. For a nonstress test to be reactive there must be two accelerations. An acceleration is defined as an increase
in fetal heart rate by 15 beats per minute, for at least 15 seconds with movement.
B is incorrect. Any decrease in fetal heart rate is a deceleration, which is an indicator of fetal distress and a nonreassuring
sign. Decelerations would lead to a nonreactive nonstress test.
C is correct. For a nonstress test to be reactive there must be two accelerations. An acceleration is defined as an increase
in fetal heart rate by 15 beats per minute, for at least 15 seconds with movement.
D is incorrect. Any decrease in fetal heart rate is a deceleration, which is an indicator of fetal distress and a nonreassuring
sign. Decelerations would lead to a nonreactive nonstress test.
E is incorrect. Variability is not a component of a NST.
F is incorrect. Variability is not a component of a NST.

NCSBN Client Need:
Topic: Health promotion and maintenance Subtopic: -
Reference: DeWit, S. C., Stromberg, H., & Dallred, C. (2016). Medical-surgical nursing: Concepts & practice. Elsevier Health Sciences.
Subject: Maternal and Newborn Health

Lesson: Antepartum
GTPAL
Gravidity
● G - Gravidity
● The number of pregnancies, including the current one
● Twins only count once! It was ONE pregnancy!
Term
● T - Term
● Number of pregnancies carried to term
● Term - 37 weeks gestation
● Twins only count once!
Preterm
● P - Preterm
● Number of preterm births
● These are births between 20 and 36+6 weeks gestation
● Twins only count once!
Abortions
● A - Abortions
● Number of pregnancies ending in abortion prior to 19+6 weeks.
○ Spontaneous
■ Miscarriages
○ Termination
● If the abortion or miscarriage was after 20 weeks gestation, it is included
under P.
Living Children
● L - Living children
● This is the current number of children alive.
● Twins will count twice here.
GTPAL Worksheet
High Risk Pregnancy

Conditions
Hyperemesis Gravidarum
What is Hyperemesis
Gravidarum?
● Extreme ‘morning sickness’
● INTENSE, intractable,
nausea AND vomiting
during pregnancy
When to be concerned
● Are they losing weight?
● Are they dehydrated?
○ Skin turgor
○ Mucous membranes
○ HR
● Electrolytes
○ Dehydration → hypernatremia
○ Vomiting excessively → hypokalemia, hypochloremia
● Dietary changes
○ Sit up after meals
○ Eat a few crackers before getting out of bed
○ Small portions
○ No liquids with meals; drink in between
○ Nothing spicy, too hot, or too cold…. Keep it simple
● Medications
○ Ondansetron
○ Promethazine
● IVF
● TPN/IL
Preeclampsia
What is preeclampsia?
● >20 weeks gestation
● Blood pressure >140/90
○ 2 times
○ 4 hrs apart
● Protein in the urine
● Eclampsia - preeclampsia leads to seizures

Assessment
● Edema
○ Hands
○ Face
● Weight gain
○ Fluid
● Headache
● Abdominal pain
● Blurry vision
● Proteinuria
● Delivery
● Prepare for a preterm baby
○ Mag sulfate → prevent seizures in mom
○ Betamethasone → Help develop baby’s lungs
● Antihypertensives…..
Antihypertensives during pregnancy
YES NO
● Labetalol ● ACE- INHIBITORS
● Nifedipine ● ARBs
● Hydralazine ○ Can cause oligohydramnios, fetal
growth restriction, and more!
Gestational Diabetes
What is Gestational Diabetes?
● GDM - Gestational Diabetes Mellitus
● Diabetes diagnosed during pregnancy
● Pancreas unable to deal with the increased insulin requirements of
pregnancy
○ Increased insulin resistance secondary to hormones released during pregnancy
○ Change in carbohydrate metabolism
Assessment
● Screen for GDM at prenatal visits
○ Glucose tolerance test at 24-28 weeks
● Screen for glucose in the urine
● Control with diet and exercise
● Monitor blood glucose
○ Mother should not require insulin after
delivery
○ Neonate at risk for hypoglycemia
● For baby:
○ Fetal pancreas produces its own insulin
○ Was used to high levels of glucose in mothers
blood
○ After delivery, no longer has high glucose
levels, but still producing that much insulin.
Ectopic Pregnancy
What is an Ectopic Pregnancy?!

● Ectopic = out of place
● An egg is fertilized, but impants outside of the uterine cavity
○ Fallopian tube
○ Cervix
○ Abdomen
● PREVENT rupture!!
○ Detect with US
○ Surgically removed
● Methotrexate
○ Stops the embryo from being able to
grow
○ Aborts the fetus
● Rh immune globulin
○ Given to mom if they is Rh negative
○ Prevent erythroblastosis fetalis
■ Don’t know Rh type of fetus
■ Better safe than sorry!
L&D Basics
Station
● How far down in the
birth canal the baby is.
● Measured in relation to
mom’s ischial spine
○ Most narrow spot
○ At ischial spine = 0 station
Fetal Heart
Rate
Monitoring
Basics
Terminology
Variability Reassuring
● Fluctuation in the fetal heart rate ● The baby looks healthy!
Acceleration Non-reassuring
● A speeding up of the fetal heart ● Something is wrong with the baby
rate
Deceleration
● A slowing down of the fetal heart

rate
Variability:
● Absent
● Marked
● Moderate
Absent Variability - Bad!
Marked variability - Can be either bad or good!

Moderate variability - Good!
Accelerations
Accelerations
Decelerations
● Early
● Variable
● Late
Early decelerations
Variable decelerations
Late decelerations
VEAL CHOP
V - Variable C - Cord Compression
E - Early H - Head Compression
A - Acceleration O - Okay
L - Late P - Placental Insufficiency
Reassuring Non-Reassuring
● Baseline heart rate in the normal ● Fetal tachycardia - HR >160
range: 110-160 ● Fetal bradycardia - HR <110
● Moderate variability ● Decreased variability
● Accelerations ● Variable decelerations
● Late decelerations
Nursing Interventions - Non-reassuring fetal heart rate

LION PIT
L: Lay the mother on her LEFT side
I: Increase IV fluids
O: Oxygen
N: Notify the healthcare provider
PIT: Discontinue Pitocin

Labor and Delivery
Complications:
Placenta Previa
Normal Previa
Assessment
● Major symptom is PAINLESS bright red bleeding
● The fact that it is painless is very important
● That sets it apart from an abruption
● To assess the bleeding
○ Pad count to determine the amount
○ Clots
○ Color
● Ultrasound done to confirm diagnosis
● Ultrasound will determine type of previa
● Never ever perform a vaginal exam if you suspect a placenta previa!
● Would never want to irritate the placenta or uterus.
● Continue to monitor for blood loss.
○ Client may have to stay on the unit to be monitored
○ Preform pad counts
○ Weigh pads
■ 1 gram = 1 mL blood loss.
● Bed rest
○ This may minimize blood loss
● Monitor baby
○ If there is excessive blood loss, perfusion to the fetus can be decreased.
● Cesarean section indicated in most cases
Labor and Delivery
Complications:
Abruptio Placentae
Anatomy
Types
● Causes massive amounts of painful bleeding.
● Two types
○ Incomplete
○ Complete
● Incomplete is only partial separation of the placenta.
○ Causes internal bleeding
○ Blood backs up behind the placenta
● Complete is when the placenta completely detaches
○ Causes massive external bleeding
○ Very painful
Assessment
● Dark red bleeding
● Intense abdominal pain
● Board like abdomen (due to internal bleeding)
● Rigid uterus
● Hypotension (Think shock due to blood loss)
● Maternal tachycardia
● Fetal bradycardia (fetal distress!!)
Interventions
● Monitor for fetal distress
○ Signs of distress? Stat c-section!
● Monitor maternal bleeding
○ Abdominal pain
○ Board like abdomen
○ Dark red vaginal bleeding
○ Change in fundal height (blood in abdomen?)
● Keep the BP up with IVF and/or blood products
● Prepare for delivery - most likely c-section.
NCLEX Question
You are triaging a new client in the antepartum unit. They tell you that they started
bleeding this morning and were told to come in by their OB. They deny any pain or other
symptoms. Which of the following nursing interventions do you anticipate initiating? Select
all that apply.
a. Bed rest
b. Pad counts
c. Emergency vaginal delivery
d. Vaginal exam
e. Ultrasound
Answer: A, B, and E
A is correct. The nurse suspects a placenta previa based off of the clients complaint of painless bleeding. With a placenta previa, bed rest is indicated to
prevent further bleeding. This is an appropriate nursing intervention to initiate for both the safety of the mother and fetus and should be done right away.
B is correct. Pad counts are a way of monitoring the quantity of blood loss. Because the nurse suspects placenta previa and the client is reporting vaginal
bleeding, pad counts are an appropriate nursing intervention to initiate. When obtaining pad counts, they can be done in two ways. If exact quantity of
blood loss is not indicated, the nurse can just count the number of pads saturated with blood. If the health care provider orders strict monitoring, the pads
will be weighed to obtain the exact number of milliliters of blood lost. When weighing pads, 1 gram is 1 milliliter of blood lost. Pad counts at a minimum
should be initiated for any suspected placenta previa, so this is an appropriate nursing intervention.
C is incorrect. An emergency vaginal delivery is contraindicated for a client with suspected placenta previa. Because we believe that the placenta is either
partially or fully covering the cervix of this client, a cesarean section will need to be performed. This may be distressing for some mothers, so be sure to
provide education about why this is the safest option for their and their baby’s health. Vagnial deliveries with a placenta previa can cause serious harm to
the mother and fetus, and are contraindicated.
D is incorrect. Vaginal exams are contraindicated for a client with a suspected placenta previa. In this client, we suspect that the placenta is either
partially or fully covering the cervix of this client. That means that if a vaginal exam were to be performed, the hand of the examiner would touch the
placenta. We do not want to cause this irritation and exacerbate the bleeding that is already occurring. Vaginal exams are always contraindicated on
clients with either confirmed or suspected placenta previa.
E is incorrect. You suspect a placenta previa, and the diagnosis for this is will be made via ultrasound, so this is an expected intervention.
NCSBN Client Need:
Reference: Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D. (2013). Maternal child nursing care. Elsevier Health Sciences.

Lesson: Labor and Delivery
Prolapsed Umbilical Cord

What is a prolapsed cord?
● Umbilical cord slips through
the cervix and into the vagina
after rupture of membranes
and before the baby
descends into the birth canal.
● During delivery, the
prolapsed cord become
compressed by the
presenting part of the fetus
● This cuts off oxygen to the
fetus
Assessment
● Cord visualized protruding through vagina
● Cervical exam
○ Something squishy?
○ Pulsing?
○ Mom feels something between legs
● Elevate the presenting part of the fetus off of the prolapsed cord
● Keep your hand on the baby’s head lifting it up and call for help
● Positioning
○ Knees-to-chest position - open the pelvis
○ Trendelenburg - let gravity shift the baby off the cord
● Administer oxygen
● Wrap cord in sterile moist towel
● NEVER ATTEMPT TO PUSH THE CORD BACK IN!!!!

● Emergency Cesarean delivery
Postpartum
Complications:
Postpartum
Hemorrhage
Risk factors for PPH
● Twins or triplets
● Macrosomic fetus
● Preeclampsia
● Prolonged labor
● Precipitous labor
● Use of forceps or vacuum during delivery
● Placenta previa
● Abruptio placenta
Assessment
● Boggy uterus
○ This is a uterus that is not contracting to clamp down on the blood vessels
○ The fundus will feel soft instead of hard as it should.
● Blood loss
○ Pad counts - most PPH clients are saturating pads every 15 minutes
○ Puddle of blood in the bed
○ If they try to stand up for the first time there could be a huge gush of blood
● Shock - if there is large amounts of blood loss leading to hypovolemia
○ Decreased LOC
○ Pale
○ Diaphoretic
○ Hypotensive
○ Tachycardic
Interventions
● Fundal massage
○ Massage the fundus - hard!
○ Warn the mother this will hurt, but you must do it to get the uterus to contract and stop the
bleeding.
○ Every 15 minutes at a minimum
● Estimated Blood Loss (EBL)
○ Weigh pads to estimate the loss
○ 1 g = 1 mL
○ Monitor hemoglobin and hematocrit
● Mediations
○ Oxytocin
○ Methylergonovine
○ Blood products
Newborn
Complications:
Meconium
Aspiration
Meconium Aspiration
Meconium is the first stool of the newborn.
When the meconium is passed before delivery,

the fetus is at risk for meconium aspiration.
The aspiration can occur in utero, or just after

delivery when the infant takes their first breath
and starts to cry.
Meconium in the lungs causes very serious

illness; pneumonia, pulmonary hypertension, and
sepsis are all common. These infants become
critically ill very quickly.
Assessment
If meconium aspiration is suspected, pertinent assessment will include:
● Respiratory status:
○ Accessory muscle use
○ Breath sounds
○ Grunting
○ Nasal flaring
Assessment to determine if meconium has been passed in utero:
● Visible meconium in fluid/on infant

● Discolored or foul smelling amniotic fluid
● Discoloration of the cord
● Discoloration of the nails/tonge on the infant
Interventions
Very quick action is essential to the outcome.
● Suction immediately after birth - before they take their first breath.
● Intubation
● IV antibiotics
● IV fluids
Newborn
Complications:
Jaundice
Terminology
● Jaundice - elevated bilirubin level resulting in yellowing of the sclera, skin,
and mucous membranes.
● Bilirubin - waste product produced during breakdown of red blood cells.
○ Unconjugated (indirect) - The heme that is released from hemoglobin in the process of red
blood cell breakdown is converted to unconjugated bilirubin. It is transported to the liver.
○ Conjugated (direct) - Unconjugated bilirubin is converted to conjugated bilirubin in the liver.

It is excreted in the stool.
Physiological Jaundice
Jaundice that appears on day 2 or 3 of life.
This is expected and not considered pathologic unless other issues arise.
This is simply due to the normal transition from the placenta removing bilirubin,
to the infant's liver doing the work.
Followed up outpatient with pediatrician.

Pathological Jaundice
Jaundice that occurs within the first 24 hours of life.
Serum bilirubin will be compared to normal value based on hours of life.
Jaundice appearing in the first 24 hours indicates some problem or disease

process that needs addressed.
Could be an issue with the liver, or an ABO incompatibility
Kernicterus
Kernicterus is a type of brain damage that can result from high levels of bilirubin
in the blood.
Complications of kernicterus:
● Cerebral palsy
● Hearing loss
● Problems with vision
● Problems with teeth
● Intellectual disabilities
Kernicterus is completely preventable! We must monitor for signs and symptoms

of jaundice early and treat promptly.
Treatment - phototherapy
● Helps break down bilirubin so it may
be excreted in the feces.
● Must ensure the eyes and genitals are
covered.
● Monitor the level and distance from
the light if overhead therapy being
used.
● Double, triple, and quadruple therapy
depending on severity.
Break Back at...

Pediatrics
Congenital
Heart Defects
Overview
Definition
● Abnormalities in the structure of the heart
● Occur during the very beginning of gestation - the heart is formed by the 8th
week of gestation!
● Commonly occur with chromosomal abnormalities and syndromes such as:
○ Trisomy 21
○ Trisomy 18
○ Turners syndrome
○ DiGeorge syndrome
Congenital Heart Defects
1. Atrial Septal Defect (ASD)
2. Ventricular Septal Defect (VSD)
3. Atrioventricular canal
4. Patent Ductus Arteriosus (PDA)
5. Tetralogy of Fallot
6. Tricuspid atresia
7. Coarctation of the aorta
8. Aortic stenosis
9. Pulmonic stenosis
10. Transposition of the great arteries (TGA)
11. Truncus arteriosus
12. Hypoplastic Left Heart Syndrome (HLHS)
Foramen ovale
An opening between the right and left atrium present in fetal circulation
Ductus arteriosus
An opening between the pulmonary artery and aorta present in fetal circulation.
Assessment
● Murmurs Left sided heart failure Right sided heart failure
● Tachycardia
● Tachypnea ● Weight gain
● Diaphoresis
● Dyspnea ● Enlarged liver
● Decreased UOP
● Grunting ● Edema
● Fatigue
● Retrations ● Ascites
● Pallor
● Nasal flaring ● JVD
● Cyanosis
● Clubbing ● Cough
● Wheezing
● Hypotension
● Prolonged capillary refill
Interventions
● Surgical interventions
● Repair vs. palliation
● Cardiac assist devices
● Pharmacologic interventions
○ Digoxin
■ Cardiac glycoside
○ Ace-inhibitors
■ Anti-hypertensive
○ Diuretics
■ Help will fluid volume overload
○ Beta-blockers
■ Decrease HR
PDA
● Machine-like murmur
● Can be closed surgically
● Alprostadil
○ Medication that can be administered to
keep the PDA open in certain heart
defects.
○ This can allow blood to get out to the body
when it otherwise couldn’t.
Tetralogy of
Fallot
Congenital malformation involving four distinct heart defects: Pulmonary stenosis,
right ventricular hypertrophy, VSD, and overriding aorta.
Tet Spells
● Hypoxic spells that occur in TOF.
● Begins with irritability and hyperpnea and
followed by a prolonged period of intense
cyanosis leading to syncope.
● A drop in systemic vascular resistance
increases the right to left shunt and
decreases pulmonary blood flow.
● More right to left shunting → more
deoxygenated blood out to the body.
Tet Spell Interventions
Comfort and calm
Knee-to-chest position
Supplemental oxygen
Sedation - morphine
Volume
Treatment
● If mild - can go home and grow until ready for surgery
● If critically ill with severe hypoxia - surgery is required in the neonatal period.
● Ideally, complete repair around 6 months of age.
● Can be earlier depending on signs and symptoms.
Coarctation
of the Aorta
Congenital cardiac condition characterized by a constriction of the

descending aorta.
Specific findings
● Upper extremities
○ Bounding pulses
○ Hypertensive
○ Warm
○ Pink
● Lower extremities
○ Weak or absent pulses
○ Hypotensive
○ Pale
○ Cool
NCLEX Question
Which of the following assessment findings would lead the nurse to believe their
client could have a coarctation of the aorta? Select all that apply.
a. +1 radial pulses and +3 femoral pulses

b. Pale, cool feet and legs with warm pink hands and arms
c. Hypertensive brachial blood pressure
d. >4 second capillary refill on the hands
e. Hypotensive popliteal blood pressure
Answer: B, C, and E
A is incorrect. In coarctation of the aorta, there is a stricture in the aorta preventing blood flow out of the left ventricle. It usually
occurs beyond the blood vessels that branch off to your upper body and before the blood vessels that lead to your lower body. So
blood flow to the upper body is abundant, but hardly any can make it to the lower part of the body. Therefore, there are decreased
lower extremity pulses, and increased upper extremity pulses. So the nurse would expect to palpate bounding +3 or +4 pulses in the
radial pulse, but weak +1 or even absent femoral pulses. This is all due to the stricture in the aorta preventing blood flow from
getting to the lower extremities.
B is correct. Pale, cool feet and legs with warm pink hands and arms would be expected in a client with coarctation of the aorta due
to the stricture in the aorta preventing blood flow from getting to the lower extremities.
C is correct. A hypertensive brachial blood pressure would be expected in a client with coarctation of the aorta due to the stricture in
the aorta preventing blood flow from getting to the lower extremities.
D is incorrect. A normal capillary refill time is <2 seconds. A >4 second capillary refill is considered delayed and is a sign of
decreased perfusion. This would be expected in the lower half of the body if the patient had a coarctation of the aorta, but not in the
hands.
E is correct. A hypotensive popliteal blood pressure would be expected in a client with coarctation of the aorta due to the stricture in
the aorta preventing blood flow from getting to the lower extremities.
NCSBN Client Need:
Subject: Pediatrics
Lesson: Cardiac
Transposition
of the Great
Arteries
A switch of the the aorta and pulmonary artery. The aorta is coming off of the
RV and the pulmonary artery is coming off of the LV. Creates two parallel and
separate tracks.
Repair
Balloon atrial septostomy - Creation of ASD to allow shunting in the unprepared
TGA client.
Hypoplastic
Left Heart
Syndrome
Disorder including 4 components: mitral stenosis or atresia, aortic

stenosis or atresia, coarctation, and a hypoplastic left ventricle.
Palliation
Norwood: birth Glenn: 2 months Fontan: 2 years
Cleft lip and

Cleft Palate
Cleft Lip
A congenital abnormality
where there is a slip, or
gap, in the upper lip on one
or both sides.
Cleft Palate
A congenital abnormality where there is a split, or gap, in the hard palate (the
roof of the mouth)
Assessment
● Visible defect
● Monitor respiratory status
● Airway patency
● Nutritional status
● Weight gain
● Hydration
Complications
● Feeding difficulties
● Weight loss
● Failure to thrive
● Speech and language delays
● Hearing issues
● Ear infections
● Aspiration
Management
● Surgically corrected
○ Cleft lip first at 3-6 months of age
○ Cleft palate second at 6-24 months of age
● Pre-operative care
○ Monitor for aspiration
○ Assess airway patency frequently
● Post-operative care
○ Positioning:
■ Position upright for feedings
■ Cleft palate - can be prone post op to help drain secretions
■ Cleft lip should NOT be prone as this could disturb the suture line
○ Protect suture line
○ Elbow restraints to avoid toddler putting things in the mouth that would compromise the sutures
○ No hard foods, straws, pacifiers, etc.
○ No oral or nasal suctioning
Feedings
● Specialized bottle to facilitate a good suction/latch
● Small, frequent feedings
● Upright position
● Burp frequently - will swallow a lot of air
● May take longer to feed than other children
● Monitor for aspiration
○ At risk for feeding to go out of their nose.
NCLEX Question
While assisting the intra-disciplinary team with interventions for a toddler who has just had
a cleft palate repair, the nurse knows which of the following are appropriate? Select all that
apply.
a. Pacifier with oral sucrose to reduce postoperative pain

b. Elbow restraints
c. Specialized bottle for feedings
d. Prone positioning
e. Oral suctioning
Answer: B, C, and D
A is incorrect. It is not appropriate to offer a toddler who is postoperative from a cleft palate repair a pacifier. This is
because there is an incision with sutures in the palate of the mouth, and placing an object there could compromise the site.
If the sutures break, the surgical site could open back up.
B is correct. Applying elbow restraints is an appropriate intervention for a toddler who has just had a cleft palate repair.
Toddlers are often putting things in their mouths, and pulling on things. It is a priority to protect their sutures, and we do
not want the toddler to be able to pull out the sutures or put anything in their mouth that would compromise the suture
line. Therefore, elbow restraints are often needed and an appropriate intervention.
C is correct. Providing specialized bottles to the toddler who has completed their cleft palate repair will be very important
for helping them establish feedings. It will be difficult for them to get good suction on a normal bottle, so specialized ones
are needed.
D is correct. Prone positioning is appropriate for the infant with cleft palate repair post-operatively to aid in drainage of
secretions and maintenance of a patent airway.
E is incorrect. Oral suctioning should be avoided after a cleft palate repair as this could disturb the suture line.
NCSBN Client Need:
Subject: Pediatric
Lesson: Endocrine
Esophageal atresia &
Tracheoesophageal
Fistula
Normal anatomy
What is tracheoesophageal fistula
(TEF)?
● A congenital abnormality in which there is an opening between the trachea
and the esophagus
What is esophageal atresia?

● Part of the esophagus does not form.
Assessment
● Choking
● Coughing
● Cyanosis
Treatment
● Pre-operative
○ NPO
● Surgery
○ Repairs the opening
● Post-operative
○ Gradual oral nutrition
Pyloric
Stenosis
What is pyloric stenosis

● Hypertrophy of the circular muscle fibers of the pylorus, with a severe
narrowing of the lumen.
Assessment
● Vomiting
○ Non-bilious
○ Projectile
○ Right after feeding
○ Infant is still hungry
● Dehydration
● Malnutrition
● Palpable pylorus
Treatment
● Correct dehydration
● Pyloromyotomy
● Nutrition after surgery
Omphalocele
What is omphalocele?
● Congenital abnormality where
the abdominal contents
protrude through the umbilicus
while remaining in the
peritoneal sac.
● Occurs during weeks 9-10 of
gestation.
● Usually diagnosed on a
prenatal ultrasound.
Assessment
● Visible defect
● Some infants have only
the omphalocele
● Some also have cardiac
defects
● Lung size can be
affected
Complications
● Hypothermia
● Dehydration
● Sepsis
Surgical repair
Management
Pre-op Post-op
● Keep exposed intestines moist ● Parenteral feeds
● Cover with sterile gauze soaked ● Trophic feeds started enterally
in saline very gradually
● IV fluids ● Monitor weight
● IV antibiotics ● Very long hospital stay
● Thermoregulation
Gastroschisis
vs.
Omphalocele
NCLEX Question
The nurse observes a parent swaddling their infant with an unrepaired omphalocele. Which
of the following statements would be appropriate?
a. “Stop, you’ll kill your baby!!”

b. “That is a nice, tight swaddle. It will really help sooth your new baby”
c. “May I help you? We will need to be careful with their intestines, we do not want
the swaddle to push them back inside.”
d. “Swaddling is not allowed for these babies, please stop.”
Answer: C
A is incorrect. This is inappropriate to say to a parent as it would cause panic and upset them. The nurse wants to
promote the parent bonding with their infant, and phrases like this will scare the parent and make them afraid to touch the
baby, which is not therapeutic.
B is incorrect. It is not appropriate to tightly swaddle an infant with an omphalocele. This would place pressure on their
exposed intestines and could push them back inside of the baby, which we do not want.
C is correct. This is a therapeutic statement. It educates the parent about the need to swaddle the baby only very loosely,
and avoid any pressure on the exposed intestines so that they do not get putheyd back inside of the baby. It also promotes
bonding with the infant, as it encourages the parent to touch and care for their baby.
D is incorrect. This is not appropriate. Swaddling is not ideal for an infant with an omphalocele due to the exposed
intestines, but if it is done loosely and avoids placing pressure on the defect it can certainly be done. Telling the parent to
stop will not promote bonding and decrease their interaction with the baby. The nurse should educate the parent on the
necessary precautions when traveling and help them develop a positive relationship with their new baby.
NCSBN Client Need:

Subject: Pediatric
Lesson: Gastrointestinal
Intussusception
What is Intussusception?
● Occurs when one part of the intestine slips inside the other intestine
● “Telescoping”
● Often occurs where the small intestine and large intestine meet.
Assessment
● Red currant jelly
stools
● Cyclical abdominal
pain
● Nausea
● Vomiting
● Green, bilious emesis
● Sausage-shaped mass
in abdomen
Treatment
● Enema to attempt to push the
intestine back out
○ Air enema
○ Hydrostatic enema
○ Barium enema
● If successful a surgical repair is
needed.
Management
Pre-op Post-op
● Monitor stool ● Monitor bowel function
● NPO ● Infection is common
● IV fluids complication
● IV antibiotics ○ Monitor temps, WBCs, CRP
● Slowly advance diet
Hirschsprung's
Disease
What is Hirschsprung's?
● Congenital aganglionic
megacolon
● Absence of enteric
neurons within the
myenteric and submucosal
plexus of the rectum
and/or colon.
● No neurons? No peristalsis
● Stool builds up and causes
a megacolon
Assessment
● Delayed passage of meconium
● Swollen belly.
● Vomiting, including vomiting a green or brown substance.
● Constipation
● Gas
● Irritation
Treatment
● Surgical removal of the portion of the colon lacking innervation
● Nutrition after surgery
Epiglottitis
What is epiglottitis?
● Inflammation of the epiglottis
● Epiglottis
○ A leaf-shaped flap in the throat that prevents food from entering the windpipe and
the lungs. It stands open during breathing, allowing air into the larynx
● Inflammation restricts the airway
● Caused by an infection
○ Bacterial
● Haemophilus influenzae type b
● Medical emergency
Assessment
● Fever
● Difficulty swallowing
● Drooling
● Stridor The 4 D’s of epiglottitis
● Tripoding
● No cough ● Dysphagia
● Change in LOC ● Dysphonia
● Cherry red epiglottis ● Drooling
● Distress
Interventions
● Tripod position
● IV antibiotics
● Avoid supine
● Humidified oxygen
● Hib vaccine has reduced incidence
● Intubation and mechanical
● Encourage parents to vaccinate to
ventilation
prevent
● Keep the child calm
● No interventions until airway is
secure
● Do not irritate the throat
○ NO tongue depressor
○ NO oral thermometer
○ NO assessing the throat
● NPO
NCLEX Question
The nurse is assessing a 4 year old who was sent to the ED from urgent care. Assessment reveals
tripod positioning, blue lips, mottled skin, inspiratory stridor, and excessive drooling. Vital signs
are:
Temp: 39 C
HR: 188
RR: 46
O2: 82 %
Which of the following should the nurse do first?
a. Keep the child calm and call for emergency airway equipment
b. Obtain IV access
c. Assess the throat for a cherry red epiglottis
d. Place the child on a high flow nasal cannula at 100% FiO2
Answer: A
A is correct. Based on the presenting symptoms, the nurse suspects that this child has epiglottitis. Any child presenting with
excessive drooling, distress, and stridor is highly suspicious for this medical emergency. In addition, this client is already showing
signs of circulatory compromise including circumoral cyanosis and mottling. The priority nursing action in this emergency is keeping
the child calm and calling for emergency airway equipment. The child is at risk of losing their airway, and airway is always the
priority!
B is incorrect. It is inappropriate to attempt to obtain IV access on a child suspected of epiglottitis before emergency airway
equipment is available. The priority action at this time is keeping the child calm and calling for emergency airway equipment.
C is incorrect. It is inappropriate to assess the throat for a cherry red epiglottis at this time. Although presence of a cherry red
epiglottis would confirm the diagnosis of epiglottitis, this child is at risk of losing their airway. The priority action will be to protect
that airway before assessing the throat. .
D is incorrect. Placing the child on a high flow nasal cannula at 100% FiO2 is not the priority at this time. This answer probably
sounded right, because you see the O2 is 82% and they have circumoral cyanosis. Oxygen sounds like the right answer! But this
intervention addresses the ‘C’ in your ABC’s - circulation. And the priority is always ‘A’, airway! This child is at risk of losing their
airway, so all interventions need to wait until there is emergency airway equipment close by. If anything upsets the child their airway
could spams and obstruct completely making it impossible to intubate them. That is why keeping the child calm and calling for
emergency airway equipment is the priority in epiglottitis clients.
NCSBN Client Need:
Subject: Pediatric
Lesson: Respiratory
RSV+
Bronchiolitis
What is bronchiolitis?
● Inflammation of the bronchioles
● Bronchioles
○ Smallest branches of the airway
○ Lead to alveoli
● Alveoli
○ Air sacs
○ Location of gas exchange in the lungs
● Thick mucus clogs up the
bronchioles
● Leads to decreased gas exchange
in alveoli
○ Air trapping
○ Collapsed alveoli
Overview
● Most common in children under 2 years old
● Seasonal illness
○ Most common in winter
● Causative agent usually viral
○ Respiratory Syncytial Virus (RSV)
● Very contagious
● Worst on days 4-6
Assessment
● Cough
● Hypoxia
● Fever ○ Circumoral cyanosis
● Increased work of breathing ○ Mottling
○ Retractions ○ Delayed capillary refill
■ Subcostal ○ Decreased SpO2
■ Intracostal ● Changes in behavior
■ Tracheal tug ○ Irritability
○ Nasal flaring ○ Lethargy
○ Head bobbing ○ Poor feeding
○ Tachypnea
● Lung sounds
○ Crackles
○ Wheezing
Interventions
Supportive treatment
● Oxygenation
○ Nasal cannula - high flow nasal cannula
○ Always humidified
● Fluid & Nutrition
○ NGT
○ Enteral feedings
○ IVF
● Antipyretics
● Analgesics
Nursing Considerations
● Continue to monitor respiratory status for changes
○ Work of breathing - improving? Worsening?
○ Continuous pulse oximetry
● Maintain airway at all times
○ Semi fowlers preferred positioning
○ Keep neck extended to open airway
■ Shoulder roll
○ Suction available
Cystic Fibrosis
What is Cystic Fibrosis?

● Autosomal recessive disorder
● Mutation leads to a buildup of excessive mucus in the airways
● Mucus leads to airway obstruction
Pathophysiology
● Mucus is both excessive and very thick
● Causes mechanical obstructions throughout the body
○ Bronchi
○ Small intestines
○ Pancreatic ducts
○ Bile ducts
Diagnosis
● Meconium ileus
○ Meconium is thicker and stickier than normal, creates a blockage and first stool doesn’t pass.
● Sweat chloride test
○ Sweat is collected and analyzed for increased levels of chloride
○ Sweat tastes salty
Assessment
● Respiratory
○ Excessive mucus ● Endocrine
○ Frequent respiratory infections ○ Diabetes
○ Hypoxemia ● Integumentary
■ Clubbing ○ Salty tasting sweat
■ Cyanosis
○ Elevated chloride in sweat
■ Barrel chest
● Gastrointestinal
● Reproductive
○ Males are infertile
○ Intestinal obstruction
○ Meconium ileus
○ Large, bulky, frothy, foul smelling stool
○ Fat soluble vitamin deficiency
■ ADEK
■ Malnutrition
■ Failure to thrive
Treatment
● Airway clearance ● Promote nutrition and growth
○ Chest physiotherapy ○ High calorie, high protein diet
○ Vest therapy ○ Increased fluid intake
● Respiratory infections ○ Monitor serial weights
○ Monitor for ○ Pancreatic enzymes
○ Treat with IV antibiotics ■ Give within 30 min of eating every
○ Prevent! meal and snack
■ Sprinkle capsules on food
● Respiratory support
■ Fat soluble vitamin replacement
○ Monitor work of breathing
○ Oxygen as needed
● Bronchodilators
NCLEX Question
The nurse is working in the normal newborn nursery. When they observes which of the
following signs, they would suspect cystic fibrosis and notify the healthcare provider for
further testing?
a. Steatorrhea
b. Hyperhidrosis
c. Meconium Ileus
d. Barrel chest
Answer: C
A is incorrect. Steatorrhea are stools that are bulk, frothy, and foul smelling. They are caused by the excretion of abnormal
quantities of fat in the stool. This does occur in cystic fibrosis, but would not be present yet in a newborn just being
diagnosed.
B is incorrect. Hyperhidrosis is a medical condition in which a person sweats excessively and unpredictably. This is not a
sign of cystic fibrosis in the newborn. The newborn with cystic fibrosis will have elevated levels of chloride in their sweat,
causing it to taste salty, but they will not sweat excessively.
C is correct. Meconium Ileus is very frequently the first sign of cystic fibrosis in a newborn. It is a bowel obstruction that
occurs when the infant’s first stool is thicker and stickier than usual, causing a blockage in the ileum.
D is incorrect. Barrel chest is a long term complication of cystic fibrosis, but not a sign that would be present at birth in
the newborn. Barrel chest refers to a broad, deep chest that is large and cylindrical. It occurs when the client has been
suffering from hypoxemia due to cystic fibrosis for a prolonged period of time.
NCSBN Client Need:

Topic: Effective, safe care environment Subtopic: Coordinated care
Subject: Pediatric
Lesson: Respiratory
Oncology
The Immune System
When things go wrong….
● Cells start dividing uncontrollably
● They may spread (metastasize) into other tissue
● The body’s immune system doesn’t flag them like it should
○ Their growth continues on unchecked
Terminology
● Benign - not cancerous
● Malignant - cancerous
● Blasts - Immature white blood cells
● Lymphoid - tissue that makes lymphocytes; lymph tissue
● Myeloid - tissue of the bone marrow
● -lymphoma - arises from the lymphoid tissue
● -myeloma - arises from the myeloid tissue
● -carcinoma - arises from the surface, or epithelium
● -sarcoma - arises from the connective tissue
Cancer stages
Chemotherapy
● Causes immunosuppression
○ Destroys cancer cells
○ Stops cancer cell growth
○ Prevents cancer cells from metastasizing
● But….this destroys healthy cells too.
Chemotherapy side effects

● Anemia
○ Fatigue
● Thrombocytopenia
○ Bleeding risk
● Neutropenia
○ Immunosuppression
○ High infection risk
● GI upset
○ Loss of appetite
○ Nausea
○ Vomiting
Chemotherapy precautions
● Chemo is administered by nurses with specialized training
○ Administered with special gloves and PPE
● Oral chemo at home
○ Only the patient and caregiver should handle the medication
○ Wash your hands before and after handling the medication
○ Wear gloves while handling
○ If the medication spills, clean the spill right away.
○ If the medication gets on the skin, wash and rinse using soap and water right away.
● Bodily fluids
○ Handle anything soiled with bodily fluids with care
○ Clean up any spills right away
○ Wash anything soiled with bodily fluids separately
Radiation
● High energy directed at cancer cells to shrink and kill them
○ X-rays
○ Gamma-rays
● Forms of radiation
○ External - machine directs beams of radiation at location of tumor
○ Internal - radioactive material placed in the body near the cancer cells
■ Brachytherapy
■ The body may give off a small amount of radiation for a short time.
External Radiation Precautions

Internal Radiation Precautions
● Wash your laundry separately from the rest of the household, including towels and sheets.
● Sit down when using the toilet (both men and women) to avoid splashing of body waste.
● Flush the toilet twice after each use, and wash your hands well after using the toilet.
● Use separate utensils and towels.
● Drink extra fluids to flush the radioactive material out of your body.
● No kissing or sexual contact (often for at least a week).
● Keep a distance away from others in your household.
● Avoid contact with infants, children, and women who are pregnant.
● Avoid contact with pets.
● Avoid public transportation.
● Plan to stay home from work, school, and other activities.
Leukemia
Leukemia
● A malignant progressive disease in which the bone marrow produces
increased numbers of immature or abnormal leukocytes. These suppress the
production of normal blood cells, leading to anemia and other symptoms.
● “Blood cancer”
Pathophysiology
● Abundance of blasts
● These underdeveloped cells can’t function
● Immunity is suppressed since these immature WBCs are not functioning
● Excessive blasts suppress the bone marrow
● Other cells in the blood begin to die due to the excess of blasts
○ RBCs → anemia
○ Platelets → inability to clot
○ WBCs → infection
Classifications
● Acute Lymphocytic Leukemia (ALL)
○ The immature cells that the body is producing too many of are lymphoid cells.
○ Most common in 2 to 5 year olds
○ Treatable and more common
○ 85% survival rate.
● Acute Myelogenous Leukemia
○ The immature cells that the body is producing too many of are myeloid cells.
○ Poor outcomes
○ 27 % survival rate
Assessment Side effects of treatment
● Weight loss ● Infection
● Fever ● Bleeding
● Infections ● Nausea
● Arthralgia ● Vomiting
● Pallor ● Loss of appetite
● Fatigue ● Weight loss
● Bleeding ● Ulcers
● Bruising ● Alopecia
Interventions
● Treatment
○ Chemotherapy
○ Steroids
○ Radiation
○ Bone Marrow transplant
● Management
○ Neutropenic precautions
○ Antibiotics
○ Antiemetics
○ Blood product administration
NCLEX Question
The nurse is taking vital signs on their client with a diagnosis of ALL. His
temperature is 38.7C. What is the nurse's first priority?
a. Place cool washcloths on the client's head.

b. Continue with their assessment
c. Obtain intravenous access on the client.
d. Assess the client's perfusion.
Answer: C
A is incorrect. Placing cool washcloths on the client's head is not the priority, there is a better answer. This would only
need to be done if the client was at risk for seizures due to an incredibly high body temperature. The temperature of 38.7C
does not warrant cooling measures, and the nurse has another immediate priority given the clients immunosuppression
and their suspicion of an infection.
B is incorrect. It is not appropriate for the nurse to simply continue with their assessment. they suspects an infection in
their client who is immunocompromised. Another answer has an immediate priority that the nurse must do.
C is correct. It is the priority action to establish intravenous access on this client. This client has a diagnosis of ALL, so the
nurse knows that he is immunocompromised. He is very susceptible to infections, and with a fever of 38.7C they has a
high index of suspicion for an infection. Broad spectrum IV antibiotics will need to be started right away, therefore it is the
priority for the nurse to start an IV.
D is incorrect. Assessing the client's perfusion has nothing to do with the nurses suspicion of an infection. they should
immediately establish IV access for the administration of antibiotics.
NCSBN Client Need:
Topic: Effective, safe care environment Subtopic: Infection control and safety
Subject: Pediatrics
Lesson: Oncology
Lymphoma
Lymphoma
● Cancer of the lymphatic system
● Affects the lymphocytes
● Impairs the body’s natural immune response
Classifications
● Hodgkin’s
○ Localized, single group of nodes
○ Reed-Sternberg cells are present
○ Extranodal involvement not
common
● Non-Hodgkin’s
○ Multiple lymph nodes are
involved
○ Reed-Sternberg cells are not
present
○ Extranodal involvement is
common
○ Most common type of lymphoma
Assessment
● Painless swelling of lymph nodes
● Fatigue
● Fever
● Night sweats
● Infections
● Weight loss
● Enlarged liver of spleen
Interventions
● Treatment
○ Chemotherapy
○ Radiation
○ Lymph node removal
● Management
○ Neutropenic precautions
○ Antibiotics
○ Antiemetics
Lung cancer
Types
● Non small cell
○ Large cell
○ Squamous cell
○ Adenocarcinoma
● Small cell
Signs and Symptoms

● Wheezing
● Cough
● Hemoptysis
● Difficulty Swallowing
Interventions
● Surgery
○ Wedge resection
○ Lobectomy
○ Pneumonectomy
● Radiation therapy
● Chemotherapy
Breast Cancer
The Facts
● Most common cancer in women
● Predisposing factors
○ Gender (females are at higher risk)
○ Age (+55 yrs)
○ Menopause
○ Genetics - BRCA1 AND BRCA2 genes.
Symptoms
● Painless lump in the breast or underarm
● Flattening or indentation on the breast.
● Change in the size, contour, texture of the breast.
● Pitted surface like the skin of an orange.
● A change in the nipple
○ Indrawn
○ Dimpled
● Unusual discharge from the nipple
○ Clear
○ Bloody
○ Any color
Breast self exam
● Done monthly
● Should occur 3-7 days after period ends.
○ After menopause, pick a date and do on that day each month.
● How to:
○
Treatments
● Lumpectomy
○ Removing the tumor from the breast
● Mastectomy
○ Removing the entire breast
● Chemotherapy
● Hormone therapy
○ Tamoxifen
Prostate Cancer
Risk Factors
● African-American males
● +60 y.o.
● Family history of prostate cancer
● Alcohol abuse
● High fat diet
● Farmers
● Painters
Screening
● Prostate Specific Antigen (PSA)
○ Blood test
● Digital Rectal Exams (DRE)
○ Done on men >40 y.o.
Symptoms
● Slow start of urinary stream
● Dribbling of urine after starting stream
● Slow urinary stream
● Straining when urinating
● Urinary retention
● Blood in urine
● Bone pain
○ Often in low back and pelvis
Treatments
● Radical prostatectomy
○ Removal of the prostate
● Chemotherapy
● Hormone therapy
Testicular Cancer
Risk Factors
● Abnormal testicle development
● History of testicular cancer
● History of undescended testicle
Symptoms
● Testicular discomfort
● Heaviness in scrotum
● Lower abdominal pain
● Enlargement of the testicle
● Change in the way the testicle feels
● Gynecomastia
○ Excessive development of breast tissue
● Lump or swelling in testicle
Treatments
● Orchiectomy
○ Removal of the testicle
● Chemotherapy
Oncologic emergencies
● Tumor lysis syndrome
● Superior Vena Cava syndrome
● DIC
Tumor Lysis Syndrome

Superior Vena Cava Syndrome
Break! Back at....

Part IV: Wrap
Up
Prioritization
Priority toolkit:
#1 - ABCs
#2 - Who is the most unstable?
#3 - Maslow’s hierarchy of needs
#4 - Nursing process
● Pain doesn’t kill your client.

● Anxiety doesn’t kill your client.
● Only call the HCP if there’s nothing YOU can do for YOUR client
● Least invasive > Most invasive
Delegation
From the Board of Nursing….
“The licensed nurse cannot delegate

nursing judgement or any activity that
will involve nursing judgement or critical
decision making”
Testing Strategies
Your test taking toolkit
The method
1. “What is this question really asking me?”
2. “Am I looking for ‘trues’ or ‘falses’?”
3. Phrase the answer choices as true or false questions.
Test taking toolkit

● Opposites can’t attract
● Sneaky similarities
● Don’t know it? Don’t guess it.
● Least invasive > Most invasive
● Eliminate what you know is wrong first.
● If part of the answer choice is wrong, the whole answer is wrong.
● Do the work yourself.
● Listen to your patient.
Understand the why.

Pharmacology questions - Group drug
classes together and remember what
their names look like. ● -pam = anti-anxiety agent
● -ptyline = TCA
● You don’t need to memorize every drug ● -pril = ACE inhibitor
from your Davis Drug Guide.

● -lol = beta blocker
● Study the major groups from the ● -mycin = antibiotic
pharmacology crash course and learn

●
what the names sound/look like.
-cillin = penicillin abx
● -azole = antifungal
● -mide = loop diuretic
Select all that apply - treat each answer

choice as a true or false question. They
are all independent of each other.
● All of the answers could be right.
● Only one could be right.

If a question asks you who is THE MOST
at risk or THE MOST likely etc….. Tally up
‘risk factors’ and choose the client with
the most!
● The might all have some risk/likelihood
● The right answer will be the client with THE MOST
● 3 risk factors wins over 2!
NCLEX Question
Which of the following clients are most at risk for postpartum hemorrhage?
a. 32 year old woman with a history of preeclampsia, prolonged labor, and use of
forceps to deliver twin pregnancy.
b. 18 year old woman with a twin pregnancy
c. 28 year old woman with known placenta previa, history of GDM, and a fetus
weighing approximately 4.8 kg.
d. 25 year old woman with a singleton pregnancy
Answer: A
A is correct. This client has FOUR risk factors. A 32 year old woman with a history of preeclampsia, prolonged labor, and
use of forceps to deliver twin pregnancy is most at risk for PPH. Preeclampsia, prolonged labor, use of forceps, and
multiples are all risk factors for PPH. This client has FOUR risk factors.
B is incorrect. This client has ONE risk factor. An 18 year old woman with a twin pregnancy is not most at risk for PPH.
Multiples is their only risk factor.
C is incorrect. This client has TWO risk factors. Known placenta previa, and a fetus weighing approximately 4.8 kg
(macrosomia) are both risk factors, but there is another client with higher risk. GDM in itself is not a risk factor for PPH, but
can lead to macrosomia which is a risk factor.
D is incorrect. This client has no known risk factors for PPH. 25 year old woman with a singleton pregnancy
NCSBN Client Need:

Reference: Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D. (2013). Maternal child nursing care. Elsevier Health Sciences.

Lesson: Labor and Delivery
Don’t freak out when you get a question on

a topic you don’t know. It’s gonna happen!
● Think back to what you DO know
● Remember the WHYs behind signs and symptoms
● Eliminate what you know is wrong

How to study from here
1. Live review
a. Attend the live course...check!
b. Review OnDemand videos to master concepts
2. Practice Questions
a. Use the Archer Qbank with 2500+ NCLEX Questions
b. Learn from each question with detailed answer rationals
c. Identify the areas you need more study on, and go back to those videos!
3. Assess your readiness

a. Launch as many readiness assessments as you would like
b. Achieve a score greater than the ‘Average Peer Score’ predictor 4 times - you are ready!
4. PASS YOUR NCLEX!!

Archerreview.com | @archernclex
Tutors:
Lexie Garber: lexie@archerreview.com
Valerie Creel: valerie@archerreview.com
Lauren Korth: lauren@archerreview.com
Rachel Taylor: rachel@archerreview.com
Cait Capablanca: cait.capa@archerreview.com
Morgan Taylor: morgan@archerreview.com
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Live NCLEX

Complete Blood Count (CBC)

Bicarbonate (HCO3) 22-28

Bicarb = BASE → metabolic

Step 2: Acidotic or alkalotic?

But… what if it’s compensated?!

Respiratory acidosis: Respiratory alkalosis: Metabolic acidosis: Metabolic alkalosis:

Putting it all together

Let’s practice together!

UNCOMPENSATED METABOLIC ALKALOSIS

Your client has the following arterial blood gas values:

COMPENSATED RESPIRATORY ACIDOSIS

● Normal sodium: 135 - 145 mEq/L

● Seizures ● Abdominal cramps ● Hypovolemia

● Increased insensible ● Hypertonic IVF ● Dehydration

The loss of ﬂuids leads to a relative

● Restless ● Twitching ● Fever ● Flushed skin

Monitor neuro status

E is correct. Dry mucous membranes are an expected ﬁnding in hypernatremia.

Subject: Fundamentals of care

● Normal potassium: 3.5 - 5.0

● Wide, ﬂat P waves

Can lead to heart block, or V-ﬁb….eventually cardiac arrest!

● Slightly peaked P wave

Subject: Fundamentals of care

● Normal calcium: 8.4 - 10.2

● Cancer of the bones

● Weakness ● Bradycardia ● Decreased ● Fatigue

● Irritability ● Hyperactive ● Weak bones

● Paresthesias ● Cramping ● Weak/brittle nails

a. The client with breast cancer and bone metastases

● Normal magnesium: 1.6-2.6 mg/dL

● Weakness ● Bradycardia ● Drowsy

● Numbness ● Psychosis ● Nausea

EKG Changes - Torsade de Pointes

Subject: Fundamentals of care

● Normal phosphorus: 3.0-4.5 mg/dL

Fluids and Electrolytes

a. Tumor lysis syndrome

a. Tumor lysis syndrome

● Normal chloride: 96-108 mEq/L

NCSBN Client Need:

Subject: Fundamentals of care

● Urine speciﬁc gravity: 1.005 to 1.030.

● 0.9% Sodium Chloride (Normal Saline)

● 0.45% Sodium Chloride (½ Normal Saline)

● 1.5%, 3%, or 5% Sodium Chloride

End result? SLOWS DOWN CLOTTING.

Important Nursing Considerations

Indication: venous thrombosis, pulmonary embolism, A-ﬁb

Action: disrupts liver synthesis of Vitamin K dependent clotting factors

● Monitor for bleeding

Test Taking Tool

D is correct. Low Molecular Weight Heparin is the drug of choice for

Action: blocks sustained high frequency repetitive ﬁring of action potentials

● Therapeutic level: 10-20 mcg/mL

Antianxiety Agents - Benzodiazepines

● Alprazolam | onset: intermediate | duration: 6-12 hours

Indication: anxiety, sedation, seizures

Action: general CNS depression