Mark Klimek NCLEX Review

Mark Klimek NCLEX Review
1. Acid Base Principles

Rule of the B’s.. If the pH & the bicarb are both in the same direction = Metabolic If they are
in different directions = Respiratory
● Values: PaO2 → 80-100 mmHg; SaO2 → 95-100%
Example: You are providing care to a client with the following blood gas results: pH 7.32, CO2 49, HCO3 29,
PaO2 80 & SaO2 90%. Based on the results, the client is experiencing: ↓ = acidosis, ↑ = respiratory
**NCLEX TIP: Don’t memorize lists, know the principle. Will test the knowledge of a principle by having you
generate lists.
● Example: In general, what do opioid pain meds do? They sedate you, CNS depressant. Symptoms you
should pick will be options that are down (lethargy, hyporeflexia, obtunded, etc)
● -Opioid: CNS depressant.. know the symptoms (sedation, respiratory depression, etc)..
**Principle: acid base signs/symptoms..

As the pH goes... so goes my patient!!!
● When pH goes up; patient goes up.. (everything gets irritable!)
● When pH goes down; patient goes down! (systems in your body shut down) …
● Except with potassium: when pH goes up; potassium goes down... when pH goes down;
potassium goes up!
pH UP ↑ K ↓ [ALKALOSIS] pH Down ↓ K ↑ [ACIDOSIS]
Tachycardia Tachypnea Bradycardia Bradypnea

Diarrhea Tremors Hypotension ↓ Lucidity
Seizure Hyperreflexia (+3/+4) Anorexia Coma
Agitated Borborygmi (↑Bowel Sounds) Lethargy Cardiac arrest
Hypertension Palpitations Suppressed, decreased, falling
Tetany Anxiety/Panic Respiratory arrest > ambu bag
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Kussmaul breathing is a deep and labored breathing pattern often associated with severe metabolic acidosis,
particularly diabetic ketoacidosis (DKA) but also kidney failure... MAC Kussmaul!! M: metabolic AC: acidosis
Example: Pt has respiratory acidosis... (select all that apply).. +1 reflexes, diarrhea, adynamic ileus, spasm,
urinary retention, tachycardia, 2nd degree mobitz type 2 heart block, hypokalemia
**NCLEX TIP: SATA questions: *never only 1... never all of them* (New change 2017: can be one answer,
some answers, or all of them). Main reason that people miss SATA questions is they select one more answer
choice then they should. If you don’t know if it applies, don’t pick the answer.
*Causes of acid-base imbalance:

○ First ask, “Is it a lung problem?” > YES → Respiratory
○ Then, ask yourself, “Are they over ventilating or under ventilating?”
i. Over ventilating > over normal > alkalosis (PaCO2 < 35)
ii. Under ventilating > under normal > acidosis (PaCO2 > 45)
iii. Ventilating doesn’t mean respiratory rate, it deal with gas exchange. Look at SaO2
value.
○ If it is not a lung problem > Metabolic
i. Prolonged gastric vomiting or suctioning > pick metabolic alkalosis because you are
losing acid and becoming more basic
ii. Everything else > metabolic acidosis
○ If you don’t know an acid-base imbalance based on a condition > pick metabolic acidosis
**NCLEX TIP: If you want to get a question right, pay attention to the modifying phrase than the original
noun.
● A person with obsessive compulsive disorder is now psychotic, you pay more attention to psychotic
than the obsessive compulsive disorder.
● If prolonged vomiting cause dehydration > you worry more about the dehydration now then the vomiting
Ventilators
High pressure alarms are triggered by an increased resistance to air flow (machine is pushing too hard
to get air into the lungs). It can be caused by obstructions:
● Kinked Tube
○ Nursing action > unkink it
● Water in tubing (caused by condensation)
○ Nursing action > empty it/remove H20
● Mucus in airway
○ Nursing action: turn, cough, deep breathe; only use suction if TCDB doesn’t work (last resort)
Low pressure alarms are triggered by a decreased resistance to air flow and can be caused by disconnections
of the:
● Tubing
○ Nursing action > pay attention to where tubing is…(contamination)
■ If tubing is on the floor, change it out
■ If tubing is on chest, clean with alcohol then put it back on
*Respiratory alkalosis ⇒ OVERVENTILATION ventilator setting may be too high.

*Respiratory acidosis = UNDERVENTILATION = ventilator setting may be too low.
What does “wean” mean? gradually decrease with the goal of getting off altogether
● ex: Doc says wean off vent in AM... 6am ABG’s show resp. acidosis... a) follow order b) call respiratory
c) hold order.. call doc d) begin to decrease the settings
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2.) Alcohol
Note: Remember in a psych question, if you are asked to prioritize > DO NOT forget Maslow!! Use the
following priorities:
1. Physiological
2. Safety
3. Comfort
4. Psychological
5. Social
6. Spiritual
Also, ALL PSYCH PATIENTS START AS MED SURG PATIENTS...RULE OUT ALL FEASIBLE MED
ANSWERS BEFORE PICKING PSYCH ANSWERS.
Psychodynamics of Alcoholism
● The #1 problem = DENIAL*refusal to accept the reality of a problem*
● You treat denial by confronting it
● Treatment:
○ Confront it by pointing out to the person the difference between what they say and what they do
○ In contrast, support the denial loss & grief, don’t confront it
■ 5 stages of grief: Denial An
ger Bargaining Depression Acceptance
○ Example: You have a pt that just hand a hand amputated & they say, “I can’t wait to get back to
playing the piano”... You say “Oh, how long have you played, etc? - you NEVER say “You can’t
because you only have 1 hand”
abuse = confront loss = support
Dependency/Codependency (#2 problem)

● Dependency: when the abuser gets the significant to do things for them or make decisions for them
● Codependency: when the significant other derives positive self-esteem from doing things for or
making decisions for the abuser.
● Treatment:
○ Set boundary (limits) and enforce them...Learn to say NO!!
○ Agree in advance on what requests are allowed than enforce the agreement
○ Work on self-esteem of the codependent person
Manipulation
● Definition: when the abuser gets the significant other to do things for him or her that is not in the
best interest of the significant other... the nature of the act is dangerous or harmful to the
significant other.
● How is manipulation like dependency? the abuser is getting the other person to do
something
○ Example: No harm = dependent / co-dependent (wife buying alcohol for husband)
dangerous/harmful = manipulated (kid buying alcohol for father) ...depends on legal/illegal.....
● Treatment:
○ Set limits and enforce them
○ It's easier to treat than dependency/codependency because nobody likes to be manipulated
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Wernicke-Korsakoff Syndrome (WKS) is a neurological disorder.
● Psychosis induced by a deficiency in the B1 vitamin thiamine.
○ Thiamine (B1) plays a role in metabolizing glucose to produce energy for the brain.
● Primary symptom of WKS = amnesia with confabulation
○ Making up stories to fill in memory los; they believe it is true
○ Example: You have a pt who believes he is Ronald Reagan's National Security Officer... And
they want to go to a cabinet meeting.../ WHAT DO YOU DO?!? Redirect!! (“well, why don’t
you get a shower and then we’ll go watch CNN and see what the news is in Washington
D.C.”)
● Characteristics:
○ Preventable
■ Give B1 vitamins
○ Arrestable
■ Can stop it from getting worse - not imply better
○ Irreversible
■ Dementia symptoms don’t get better - only worse
**NCLEX Tip: Always answer with the majority
Antabuse (disulfiram)/Revia -alcoholism medication *aversion therapy!*

● It can treat problem drinking by creating an unpleasant reaction to alcohol. It's used in recovery programs
that include medical supervision and counseling.
● Onset and duration of effectiveness > 2 weeks
○ Take drug for 2 weeks and builds up in the blood level that when drinking alcohol, they will
become horribly sick
○ If they stop taking the drug for 2 weeks, they will be able to drink alcohol without getting sick
● Patient teaching - Avoid ALL forms of alcohol to avoid nausea, vomiting and possibly death
○ NO: mouthwash, aftershaves, perfumes/colognes, insect repellants, any OTC elixirs
(ex: Robitussin), alcohol-based hand sanitizers, un-cooked icings (vanilla extract)...
○ However, they CAN have RED WINE VINAIGRETTE!
*Overdoses/Withdrawals...
First ask yourself, “Is the drug an upper or a downer?”
● Exception > Laxative (not upper or downer) but can be abused by the elderly..
Uppers ↑ Downers ↓
Names: Names
● Caffeine ● Everything else that is not an upper
● Cocaine
● PCP/LSD (Psychedelic hallucinogens)
● Methamphetamines - speed
● ADHD - adderall/Ritalin
● Bath Salts (Cath-Rath)
Signs/Symptoms: Signs/Symptoms:
Tachycardia Hypertension Bradycardia Hypotension
Diarrhea Agitation Constipation Constricted pupils
Tremors Clonus Flaccidity Respiratory arrest
Belligerence Seizures Decreased core body temp Lethargy
Exaggerated, shrill, high pitched cry Hyporeflexia
Difficult to console Borborygmi
Euphoria Hyperreflexia **Need Ambu bag
**Need suction
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Then ask yourself, “Are they talking about overdose or withdrawal?”
Overdose/Intoxication Withdrawal
“I have too much…” “I don’t have enough…”
Too much upper: > Everything is UP ↑↑ Too little upper: > Everything is DOWN ↓↓
Too much downer: > Everything is DOWN ↓↓ Too little downer: > Everything is UP ↓↓
Upper overdose LOOKS LIKE downer withdrawal

Downer overdose LOOKS LIKE upper withdrawal
2 situations (highest priority):

● Respiratory depression/arrest: Downer overdose/upper withdrawal..
● Seizure: Upper overdose/downer withdrawal...
○ Example: Overdose on cocaine: UPPER/OVERDOSE.. (too much UPPER) *aka everything
goes ↑ * What would you expect to see? (select all that apply) -irritability, reflex 3/4,
increased temp, borborygmi (increased bowel sounds), respirations < 12, difficult to arouse
Drug addiction in the NEWBORN ☹ Always assume intoxication, not withdrawal at birth
● Before 24 hours- it’s intoxicated
● After 24 hours - it’s in withdrawal
● Example: You are caring for an infant born to a equaline (pain killer) addicted mother... It is 24 hours
after the birth... What do you expect to see.. SELECT ALL THAT APPLY: difficult to console, low core
body temp, exaggerated startle reflex, respiratory depression, seizure risk, shrill high pitched cry...
Alcohol Withdrawal Syndrome vs. Delirium Tremens

● Differences:
○ Every alcoholic goes through alcohol withdrawal syndrome (AWS) after 24 hours
○ Only a minority get delirium tremens (DT’s)
○ AWS is not life threatening. DTs can kill you
■ Patients with AWS are usually stable and not dangerous to themselves or others
■ Patients with DT’s are usually unstable and are dangerous to themselves and others
AWS DT’s BOTH
Semi-private room Private room Anti-hypertensives

Anywhere on the unit Near nurse’s station
Regular diet NPO or Clear Liquids Tranquilizer
Up Ad Lib (no activity restrictions) Restricted bedrest (no bathroom B1 multi-vitamin

privileges, bedpan/urinal) (to prevent dementia)
Do not restrain Should be restrained

(2 point leather restraints)
2 extremity restricted- L arm/R leg or
R arm/L leg
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**Aminoglycosides - powerful antibiotics (the BIG GUNS!!!) think: a mean old mycin
● Treats serious, life threatening, resistant, gram negative infections (TB, septic peritonitis, fulminating
pyelonephritis, septic shock, infection of third degree burns over 80% of your body, etc.)
● Examples: Streptomycin, Cleomycin, Tobramycin, Gentamycin, Vancomycin, Clindamycin
● Not all drugs that end in mycin are aminoglycosides: erythromycin, zithromycin, clarithromycin / if it has
thro = throw it off the list...
● Toxic Effects:
○ The most famous feature on the world’s famous mouse (Mickey Mouse’s ears)
■ Toxic effect > ototoxic!!
■ Monitor hearing, tinnitus (ringing in ears), vertigo/dizziness (equilibrium)
○ The human ear shaped like kidney...
■ Toxic effect > nephrotoxicity!
● Monitor creatinine (best indicator for kidney function)
● Normal range: 0.6-1.2 mg/dL
○ The number 8 drawn in the ear reminds you of:
■ Cranial nerve #8 (can cause hearing loss)
■ Frequency of administration: Every 8 hours
● Route of Administration:
○ Give IM or IV
○ Do not give PO (it is not absorbed) except in these two cases:
■ Hepatic Encephalopathy
● Also called liver coma, ammonia-induced encephalopathy
● When you want a sterile bowel
● Due to high ammonia levels
■ Pre-Op Bowel Surgery
● Remember military sound-off:
○ NEOmycin
○ KANamycin
○ Who can sterilise my bowel? NEO KAN
● Trough and Peak Levels
○ T (trough): when the drug level is at its lowest
○ A (administer)
○ P (peak): when the drug level is at its highest
■ Why do we draw TAP levels? Narrow therapeutic range
○ Time Table:
ROUTE TROUGH (lowest) PEAK (highest)
Sublingual 30 min before next dose 5-10 min after drug dissolves
IV 30 min before next dose 15-30 min after drug finished
IM 30 min before next dose 30-60 min after drug is given
SubQ 30 min before next dose See diabetes lecture
PO 30 min before next dose Forget about it
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BIOTERRORISM
● Categories of Biological Agents
○ Category A (most serious)
■ Smallpox
● Inhaled transmission/on Airborne Precautions
● Dies from septicemia. Blood infection. *only class A that dies
● from this.
● Rash starts around mouth first (early ID & isolation is crucial
● to contain)
■ Tularemia
● Inhaled
● Chest symptoms (coughing, chest pain, sputum)
● Dies from respiratory failure
● Treat with Streptomycin (watch hearing and creatinine)
■ Anthrax
● Spread by inhalation
● Looks like flu (chest symptoms and achy muscles)
● Treat with Cipro, PCN, and streptomycin
■ Plague
● Spread by inhalation
● Has the 3 H’s:
○ Hemoptysis (coughing up blood)
○ Hematemesis (vomiting blood)
○ Hematochezia (bloody diarrhea)
● Dies from respiratory failure and DIC
● Treat with Doxycycline and Mycins
● No longer communicable after 24 hours of treatment
■ Hemorrhagic fever (Ebola)
● 21 day time frame
● Primary symptoms are petechiae and ecchymosis
● High % fatal
● Die of DIC
■ Botulism
● Ingested (drink/eat)
● Has 3 major symptoms:
○ Descending paralysis (starts at head-goes down to diaphragm)
○ Fever
○ But is alert
○ Category B
■ All others (long list)
○ Category C
■ Hantavirus
■ Nipah virus
● Chemical Agents
○ Mustard Gas → Blisters (Vesicant, eventually cover airway)
○ Cyanide → Respiratory arrest. Treat with Sodium Thiosulfate IV
○ Phosgene chloride → Choking
○ Sarin → Nerve agent.
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■Symptoms (Cholinergic Effects):
● Bronchorrhea
● Bronchoconstriction
● Salivation
● Lacrimating
● Urination
● Diaphoresis/diarrhea
● GI upset
● Emesis
○ All chemical agents require only soap and water cleansing except for Sarin, which requires a
bleach
■ Nursing Actions: Bioterrorism- Isolation, Antibiotics
■ Chemical: Decontamination
● Send all suspected cases to decontamination center
● Remove all clothing
● Chemical hazard double bag
● Incinerated
● Shower in soap and water (bleach- sarin)
● Discharged in government clothes
3. Cardiac and Meds

**Calcium Channel Blockers are like VALIUM for your
Tachy = yes it needs to relax
💓
!!! ...calms the heart down!
Shock = no it does not need to relax
Digoxin is the only drug that mixes + and - effects; other 99% have either + or - effects
CCB are negative inotropic, chronotropic, dromotropic
Apical pulse: best assessed at the apex of the heart/mitral area. It is located at the fifth intercostal space on
the midclavicular line.
ACTION DEFINITION POSITIVE ↑ NEGATIVE ↓

Cardiac Stimulant Cardiac Depressant
Inotropic Strength of heartbeat Strong Weak
Chronotropic Rate of heartbeat Fast Slow
Dromotropic Conductivity Excitable Blocks/Slows conduction
What do Calcium Channel Blockers treat? (indications)

● Antihypertensives (BP way UP- relaxes heart and blood vessels)
● Antianginal (relaxes heart- reduces O2 demand)
● Anti Atrial Arrhythmia (does not treat ventricular arrhythmias; treats Afib/Aflutter and SVT)
Calcium Channel Blocker side effects:

● Headache (vasoconstriction in the brain)
● Hypotension (relaxes heart and blood vessels)
● Bradycardia
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Names of Calcium Channel Blockers:
● Verapamil
● Cardizem (can be given as a continuous IV)
● -dipine
Nursing Actions: before administering CCBs→ Check BP, if systolic lower than 100 → Hold and call MD
● If on a drip, titrate drip to keep systolic over 100
Cardiac Arrhythmias
● Terminology
○ P wave > atrial
○ QRS depolarization > always refers to ventricular
● Rhythms you must know for NCLEX > NSR, V-Fib, V-Tach, Asystole
**Normal Sinus Rhythm

● P wave
● QRS complex evenly spaced
● T wave
● Regular rhythm
Atrial Fibrillation
● Chaotic P-wave depolarization
● Lack of any discernible pattern
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Atrial Flutter
● Rapid P-wave depolarizations
● Saw-tooth pattern
**Ventricular Fibrillation
● Chaotic QRS depolarization
● No pattern
● Lethal arrhythmia
● Treatment
○ Beat to treat electrically
○ Shock = 200 defibrillate
**Ventricular Tachycardia
● Wide, bizarre QRS complexes
● Tachy is always discernible repeating pattern
● Potentially life-threatening arrhythmia
○ Pulseless V-tach is the same as asystole and V-fib and
would depend on how long down
○ After 8 min > consider dead
● Treatment
○ Lidocaine
**Asystole
● A lack of QRS depolarization
● Lethal arrhythmia
● Treatment
○ Epinephrine
○ Atropine
○ S/E anticholinergics
Premature Ventricular Complex

● Periodic wide, bizarre QRS
● Generally low to moderate priority, unless everyone else has a
normal rhythm
● Be concerned, if:
○ More that 6 per min
○ 6 in a row
○ PVC falls on the T-wave of previous beat
● Treatment
○ Lidocaine (Ventricular, last longer)
○ Amiodarone
Supraventricular arrhythmias
● Treatment
○ Adenosine (push fast IV push; usually 8 seconds or faster)
○ Beta blockers
○ Calcium Channel Blockers
○ Digoxin (Digitalis) Lanoxin
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*LETHAL arrhythmias (High Priority)
● They will kill you in 8 minutes or less
○ Asystole
○ V-Fib
● They both have: NO cardiac output (pulse) → NO brain perfusion.
Potentially life threatening arrhythmia →V-Tach (they have cardiac output → pulse)
● Pulseless V-Tach: treat the same as asystole and V-Fib
● It would depend on how long the person has been down →After 8 mins, they are considered dead
Treatments
● PVC’s
○ Lidocaine (Ventricular, lasts longer)
○ Amiodarone
● V-Tach
○ Lidocaine
○ Amiodarone (using more coming April 2019)
● Supraventricular arrhythmias (SVT)
○ Adenosine (push fast, usually 8 sec or faster > watch for asystole but they will come out
of it) Have crash cart near by
○ Beta Blockers
○ Calcium Channel Blockers
○ Digoxin (Digitalis)→ Lanoxin
● V-Fib
○ Best to treat with electricity
○ Shock > 200 Defibrillate
● Asystole
○ Epinephrine
○ Atropine
○ S/E anticholinergics
Anticholinergic Effects Cholinergic Effects
↓ Mucus Bronchodilation Bronchorrhea (large amounts of mucus in airway)

Dry mouth Dry eyes Bronchoconstriction Salivation
Urinary retention Dry skin Lacrimating Urination
Constipation Shuts down GI Diaphoresis/Diarrhea GI upset
Prevents V when trying to intubate Emesis
CHEST TUBES
The purpose for chest tubes is to re-establish negative pressure (negative pressure makes things stick
together) in the pleural space. They are used for lobectomy and wedge resections
● Pneumothorax → removes air ( air = positive pressure pushes things away)
● Hemothorax → removes blood (blood = positive pressure pushes things away)
● Pneumohemothorax → removes air and blood (air & blood = positive pressure)
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LOCATION of the tube:
● APICAL (high for air)
○ Label “A” → up high, apex/top of lung
● BASILAR (bottom for blood)
○ Label “B” → placed at base/bottom of lung
Examples:
● How many chest tubes (and where) for unilateral pneumohemothorax?
○ 2 ⇒ apical and basilar all on the side of the pneumothorax
● How many chest tubes (and where) for bilateral pneumothorax?
○ 2 ⇒ apical on right and left sides
● How many chest tubes (and where) for post-op chest surgery?
○ 2 ⇒ apical and basilar on the side of the surgery
○ Exception: If surgery total pneumonectomy then → no chest tube because no pleural
space
○ Always assume chest trauma and surgery is unilateral, unless otherwise specified
**Only clamp chest tube in an emergency
Water Seal Chest Tube Dry Seal Chest Tube
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TROUBLESHOOTING:
● What do you do if you kick over the collection bottle?
○ Not a big deal; can just sit it right back up; have take a couple deep breaths
● What do you do if the water seal breaks?
○ This is more serious, because it is allowing air in creating a 2 way
○ First: Clamp chest tube then cut tube away from broken device
■ **In routine care never clamp chest tube!!**
○ Best: Submerge the tube under sterile water, then unclamp it because you have
re-established the water seal. It is better for the tube to be under water than to be clamped
because underwater → air can’t go in, but stuff can come out. If it is clamped, nothing can go in
or out.
○ Order → Clamp, Cut, Submerge, Unclamp
● What do you do if the chest tube comes out/gets pulled out?
○ First: cover hole with gloved hand
○ Best: cover it with vaseline gauze; put a dry sterile dressing on top and tape it on 3 sides
**NCLEX TIP: KNOW FIRST vs BEST... Example: Patient is in V-Fib on the monitor.. BAD, you run to the
room and they are unresponsive with no pulse! FIRST thing you should do → place backboard.. BEST thing to
do → chest compressions
● FIRST questions is asking about order
● BEST questions is asking if you could only do one thing, what would be the best thing to do is?
● Bubbling
○ Ask yourself two questions:
■ WHERE is it bubbling
■ WHEN is it bubbling
○ Sometimes bubbling is good & sometimes it’s bad - depends on where & when!
■ Where? Water seal.. When? Intermittent = GOOD! Document that!
■ Where? Water seal... When? Continuous = BAD! ⇒ LEAK... You do not want
continuous bubbling in the water seal. Find the leak and tape it until it stops leaking
■ Where? Suction control chamber.. When? Intermittent = BAD... Suction is not high
enough, turn up suction on the wall
■ Where? Suction control chamber.. When? Continuous = GOOD.. Document that!
○ *If something is sealed, should you have a continuous bubbling? NO.
○ Straight cath is to a foley catheter as a thoracentesis is to a chest tube..
Rules for clamping a tube:

● Do NOT clamp longer than 15 seconds without a doctor’s order...
● What happens if you break the water seal? CLAMP it! How long do you have to get it under water? 15
seconds, or you gotta unclamp..
○ Have sterile water bottles nearby! Use rubber tip double clamps...
■ Rubber so you do not puncture the tube
CONGENITAL HEART DEFECTS

Every congenital heart defect is either TROUBLE or NO TROUBLE (no in between)
TRouBLe
● T → All CHD’s begin with “T” are trouble; exception → Left ventricular hyperplasic syndrome
● R - L → Blood shunts
● B → Cyanotic
● Trouble defect shunts blood: RIGHT to LEFT (cyanotic, blue); needs surgery, delayed growth,
decreased life expectancy, needs more time in the hospital/pediatric cardiologist
● NO-trouble defect shunts blood: LEFT to RIGHT (acyanotic, pink); doesn’t need surgery, normal
growth, normal life expectancy, only 24-36 hours in the hospital/pediatrician/NP..
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40 some congenital heart defects..
Examples of “TROUBLE” Heart Defects Examples of “NO TROUBLE” Heart Defects
RIGHT to LEFT → Blue LEFT to RIGHT → Pink
Tetralogy of Fallot, Truncus Arteriosus, Transposition Ventricular Septal Defect, Patent Ductus Arteriosus,
on the great vessels, Transposition on the great arteries, Patent Foramen Ovale, Atrial Septal Defect, Pulmonic
Tricuspid atresia, Total anomalous pulmonary venous Stenosis
return (TAPV), Left Ventricular Hyperplastic Syndrome
ALL congenital heart defect kids (whether trouble or not) will have 2 things in common:
● They will all have a murmur (because the shunt of the blood)
● They will all have an ECHO done
**4 defects of tetralogy of fallot:

● VarieD ⇒ VD (ventricular defect)
● PictureS ⇒ PS (pulmonary stenosis)
● Of A ⇒ OA (overriding aorta)
● RancH ⇒ RH (right hypertrophy)
MATH
● IV DRIP RATES... volume x drop factor / time in minutes (volume/hours)
○ DROP FACTOR ⇒ Micro drops: 60 drop/ml Macro drops: 10 drops /ml
● PEDIATRIC DOSE: child's weight → 2.2 lbs per kg
○ NCLEX will ask for kg → will always be dividing by 2.2
○ Pay Attention to: amount per day or amount per each dose
● Always ROUND at the END!!! (NCLEX will tell you to where)
○ Use leading zero as long as it keeps place value; do not use trailing zeros
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4. Crutches, Canes & Walkers
Locomotion (human functioning): cast, traction, canes, crutches, walkers
CRUTCHES: how do you measure? (for risk reduction so you do not cause nerve damage)
● Length of crutch: 2-3 finger widths below the anterior axillary fold to a point lateral to and slightly in
front of the foot
● Hand grip: when properly set, the elbow flexion will be about 30 degrees..
-How to teach how to use the different type of crutch GATES:

● 2 point: 1 crutch/opposite foot together.. other crutch/other foot together
○ Step One: Move one crutch and opposite foot together
○ Step Two: Move other crutch and other foot together
○ Remember: 2 points together for a 2 point gait
○ Examples: one knee replacement
● 3 point: moving 2 crutches & the bad leg
○ Step One: Move two crutches and bad leg together
○ Step Two: move good foot by self
○ Remember: 3 point is called 3 point because three points touch down at once
○ Examples: Stairs
● 4 point: move everything separately
○ Step One: One crutch
○ Step Two: Opposite foot
○ Step Three: Other Crutch
○ Step Four: Other food
○ Examples: total both knee right after surgery
● Swing-through: for two braced extremities
○ NON-weight bearing.. *amputations* plant the crutches & swing through
○ Example: arthritis braced legs
● WHEN TO USE EACH GAIT??
○ Use the even numbered gaits (2&4 point) when weakness is evenly distributed (bilateral).
■ Two point for mild problem; four-point for severe problem
○ Use the odd numbered gait (3 point) when one leg is odd (unilateral problem)
○ Examples of what crutch gait to use:
■ Early stages of RA → 2 point
■ Left above knee amputee → swing through
■ 1st day post op R total knee replacement, partial weight bearing allowed → 3 point
■ Advanced stages of ALS → 4 point
■ Left hip replacement, 2nd day post-op, non-weight bearing → swing through
■ Bilateral total knee replacement,1st day post-op, weight bearing allowed → 4 point
■ Bilateral total knee replacement, 3 weeks post-op → 2 point
● Stairs:
○ Which foot leads when going up and down stairs on crutches?
■ Remember: UP with the good; DOWN with the bad
○ The crutches always move with the bad leg
● Cane
○ Hold can on the strong (unaffected) side
○ Advance cane with the weak side for a wide base of support
● Walkers
○ Pick it up, set it down, walk to it
○ Tie belongings to side of walker, not the front to prevent tipping over
○ Getting out of chair to walker- always push, never pull (same for cane, crutches)
○ No wheels/tennis balls (per boards!)
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DELUSIONS, HALLUCINATIONS & ILLUSIONS: *PSYCH*
Is my patient NON-psychotic vs. psychotic? (1st thing you must decide)
● NON psychotic (neurotic): has insight and reality based
○ They know they have a problem
○ They need “good therapeutic communication”
■ Examples:That must be very difficult; How are you feeling?, What do you mean by…?,
Can you tell me more?
● Psychotic: has NO insight & is not reality-based
○ They don’t believe they are sick
○ They believe everyone else has a problem and blame everyone else
○ Therapeutic communication doesn’t work with these patients
■ Use unique, specific strategies
○ SYMPTOMS: delusions, hallucinations & illusions
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Delusion
● Definition: a delusion is a false, fixed belief, idea or thought. There is no sensory component.
● Three types of delusions:
○ Paranoid or Persecutory: false, fixed belief that people are out to harm you.
○ Grandiose: False, fixed belief that you are superior
○ Somatic: False, fixed belief about parts of your body
Hallucinations
● Definition: a hallucination is a false, fixed sensory experience
● Five types of hallucinations:
○ Auditory (most common* hearing)
○ Visual (second most common)
○ Tactile
○ Olfactory (smelling)
○ Gustatory (tasting)
Illusions
● Definition: An illusion is a misinterpretation of reality. It is a sensory experience.
● Differentiation between illusions & hallucinations: with illusions there is a referent in reality ( something
to which they can refer to)
● Example:
○ If a client says, “I hear demon voices.” This is an example of a hallucination WHY? It is
sensory and there was nothing there.
○ A client overhears nurses and doctors laughing and talking at the nurse’s station and says,
“Listen, I hear demon voices.” This is an example of an illusion WHY? There are real people
making real sounds that they misinterpreted.
When dealing with a patient experiencing delusions, hallucinations or illusions, first ask yourself, “What is their
problem?”
● FUNCTIONAL psychosis Psychosis of Dementia
● Psychotic Delirium
FUNCTIONAL PSYCHOSIS
● These are:
○ Schizophrenia
○ Schizoaffective disorder
○ Major depression
○ Mania
● They can function in society
● Patient has the potential to learn reality (No brain damage)
○ Use 4 step process to teach ⇒ Acknowledge the feeling, present reality, set a limit, enforce
the limit.
○ Example (answer):
■ 1-FEELING: I see you’re angry, you seem upset, tell me more of how you’re feeling
■ 2-REALITY: I know that the voices are real to you, but they are not real... I’m a nurse,
this is a hospital
● Choose the positive answer rather than the negative one
■ 3-SET LIMIT: That topic is off limits in our conversation. We aren’t going to talk about
that...
■ 4-ENFORCE LIMIT: I see you are too ill to stay reality based, so our conversation is
over (it ends the conversation, not taking away a privilege, this is a punishment)
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PSYCHOSIS OF DEMENTIA
● These are:
○ Alzheimer's
○ Senility/Dementia
○ Organic Brain Syndrome
○ Post Stroke
○ Wernicke's
● This person has a brain destruction problem and can NOT learn reality
● 2 steps:
○ Acknowledge the feeling
○ Redirect them (channel them from something they can’t do to something they can do)
● Reality Orientation: person, place & time (always appropriate)... but DON’T present reality because
they can’t learn it and they will get frustrated
PSYCHOTIC DELIRIUM
● Description: Episodic, temporary, sudden onset, dramatic, loss of reality, secondary to a chemical
imbalance
○ Due to: UTI in elderly, thyroid imbalance, electrolyte imbalance, Post-Op patients, ICU
psychosis
● Two steps:
○ Acknowledge their feeling
○ Reassure (it will get better, I will keep them safe)
Example: You have a patient with schizoaffective disorder who points to two people talking at a table across
the room. He says “Those people are plotting to kill me.” What would you say, as a nurse?
● Most important word in the example: Schizoaffective disorder → Functional psychotic category
● You tell them, “I see that you are sacred. That must be frightening. Those people are not plotting to
kill you, we are all safe.” {presenting reality}
● Then tell him we are not going to discuss this. If he still talks about the two people, you say “ I see
that you are too ill right now, so the conversation is over. We can meet in 1 hour and maybe have a
reality based conversation.”
Example: You have a patient with alzheimer's disease who during your conversation, points to two people
sitting at a table and says “You see those two people at the table, they are plotting to kill me.”
● Most important word in the example: Alzheimer’s disease → Psychosis of dementia
● Acknowledge feelings: You seem scared, that must be frightening
● Redirect: Let's go someplace where you feel safe
Example: A client with DT’s says to you, “You see those two people at the table, they are plotting to kill me.”
● Most important word in the example: DT’s → Psychotic delirium
● Acknowledge feelings: I see that you are scared; you are safe and that feeling will go away when
you get better
● Redirect: Let's go someplace where you feel safe
Loosening of Association
● Thoughts are all over the place
● Flight of ideas: go from thought to thought to thought; stringing phrases together
● Word salad: babble random words (sicker); string words together
● Neologism: making up words
Narrowed self concept:

● When a (functional) psychotic refuses to leave their room or change their clothes...
○ Self concept: how they define who they are
● NURSE would say: “I see you feel uncomfortable.. You do not have to change your clothes or leave
the room until you feel comfortable or are ready.”
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Ideas of reference: when you think everyone is talking about you...
5. Diabetes Mellitus
Definition: DM is a error of glucose metabolism
● Do not confuse DM with Diabetes insipidus
● Diabetes insipidus →polyuria (high urine output), polydipsia, leading to dehydration → due to low
ADH/just the fluids
● SIADH (opposite of DI): oliguria (low urine output) and retaining water (gains weight suddenly)
○ The less the urine out; the higher the specific gravity.The more the urine out; the lower the
specific gravity → SIADH ↑ specific gravity; DM/DI ↓ specific gravity
Example:
● Who has a urine output of 300 mL/hr for the last 3 hours and a normal BS? ⇒ DI
○ Nursing Dx → Fluid volume deficit
● Who has a urine output of 300 mL/hr for the last 3 hours and a BS of 280? ⇒ DM
○ Nursing Dx → Fluid volume deficit
● Who has a urine output of 20 mL/hr for the last 3 hours and a normal BS? ⇒ SIADH
○ Nursing Dx → Fluid volume excess
● Type I ● Type II
○ Insulin dependent ○ “Non” all the above
○ Juvenile Onset ○ “Non” insulin dependent
○ Ketosis prone (tend ○ “Non” juvenile onset → adult
to make ketones ○ “Non” ketosis prone
Signs and Symptoms

● Polyuria (increased urine)
● Polydipsia (increased thirst)
● Polyphagia (increased eating/swallowing)
TREATMENT
● Type 1
○ DIE... diet (least important), insulin (most important), exercise
● Type 2
○ DOA... diet (most important), oral hypoglycemic, activity
○ DIET: calorie restriction, 6 small, frequent meals
● Insulin acts to lower blood sugar
○ Hypoglycemia occurs at the peak time of insulin
○ ALWAYS check expiration dates!! (manufacturer’s expiration date is only good when the
bottle is closed... after it’s open; it expires in 30 days!) *make sure you write the date on the
bottle!* Write open/EXP and date you opened it
○ You should teach patients to refrigerate their insulin at home, but it doesn’t need to be
refrigerated in the hospital.
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Types of Insulin Onset Peak** Duration
Rapid Acting
**LISPRO (Humalog) 15-30 minutes 1-2 hours 3-6 hours

(fastest acting; give with meals)
ASPART (Novolog) 15-30 minutes 1-2 hours 3-6 hours
Short Acting
**REGULAR (Type R) 1 Hour 2 hours 4 hours

(clear solution; rapid; run- IV drip)
Intermediate Acting
**NPH (Type N) 6 hours 8-10 hours 12 hours

(cloudy suspension; do not put in an IV bag, not so
fast)
Long Acting
**GLARGINE (Lantus) Slow absorption; 1 No peak; no/low risk of 12-24 hours

(long acting insulin; can safely give at bedtime) hour hypoglycemia
DETEMIR (Levemir) 1-2 hours None 19-20 hours
● Exercise potentiates (decreases) insulin:

○ Another shot of insulin
○ More exercise (more insulin) = really need less insulin
○ Less exercise = need more insulin
● SICK days: glucose is going to go up..
○ Still take insulin, even if they’re not eating
○ Take sips of water; they get dehydrated fast ⇒ HYPERGLYCEMIA & DEHYDRATION
○ Needs to stay active as possible
**COMPLICATIONS (must know for NCLEX)

● Low Blood Sugar in Type I DM (=insulin shock) [Hypoglycemia]
○ Causes:
■ Not enough food
■ Too much exercise
■ Too much insulin (#1 cause)
○ Danger:
■ Permanent brain damage
○ Signs and Symptoms:
■ Drunk + shock
■ Cerebral impairment & vasomotor collapse (blood vessel wall muscles don’t have
enough E to maintain tone) → slurred speech, staggered gait, abnormal reaction time,
labile/uncontrolled emotions, lowered BP, increased pulse, skin pale, cold, clammy,
mottled, inattentive to social boundaries, increased respirations
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○ Treatment:
■ Administer rapidly metabolizable carbohydrates (sugar)
● Any juice, candy, milk, honey, icing, jam
● Ideal combination: food with sugar and protein (& maybe starch)
○ ORANGE juice & crackers! apple juice & slice of turkey... 1/2 cup skim
milk (has both sugars & protein)
● Bad combinations: bottle of soda and candy; sugar packs in juice
■ If unconsciousness: Nothing oral! Glucagon IM, Dextrose (D10/D50) IV
● High Blood Sugar in Type I DM- DKA Diabetic Coma [Hyperglycemia]

○ Causes:
■ Blood glucose too high >600
● Too much food
● Not enough insulin
● Not enough exercise
■ #1 cause is acute viral upper respiratory infection within the last week or two
○ Signs and Symptoms:
■ Dehydration (appear dry, hot, flush, HA, pulse weak, thready, increase in temp)
■ Ketones (in urine & blood); increase in K+; Kussmaul respirations
■ Acidotic; acetone (fruity) breath; anorexia due to nausea
○ Treatment
■ IV with regular insulin @ 200/hr at high flow rate
■ Normal saline/D5 ⇒ D5 doesn’t stay in veins; goes into the tissues.. won’t cause
HYPERGLYCEMIA (D10 & D50 will!)
■ Higher priority in the ER; would die before HHNK
● Low Blood Sugar in Type II DM (Hypoglycemia)

○ Treatment is the same as for low BGM in Type I Diabetes
● High Blood Sugar in Type II DM (Hyperglycemia)

○ Called HHNK (or HHNC)
■ Hyperosmolar, hyperglycemic, non-ketotic coma
○ This is severe dehydration
○ Signs & symptoms are like S&S of dehydration
■ Including: increased temp
○ Treatment: rehydrate (glucose will usually turn to normal on own)
○ More life-threatening than DKA
● Long term complications are related to two problems:

○ Problems with tissue perfusion
■ Renal failure, poor wound healing
○ Peripheral neuropathy (nerve damage)
■ Loss control of bladder and now incontinent
● Which lab test is the best indicator of long-term BGM control (compliance/effectiveness) ?
Hemoglobin A1C
○ A1c = average glucose rate over 3 months
○ Want A1C less than 6!!!
■ HA1C for dx → >6.5-7 → DM/pre DM
■ Monitoring tx → >8.0 out of control
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.
6. Drug Toxic **KNOW**
DRUG THERAPEUTIC LEVEL TOXIC LEVEL
Lithium 0.6-1.2 > 2

(antimanic drug for Bipolar mania)
Lanoxin 1-2 > 2

(Digoxin; used for Afib and CHF)
Aminophylline 10-20 > 20

(Airway Antispasmodic *NOT a
bronchodilator*, give aminophylline to relax
the spasm; then give the bronchodilator)
Dilantin 10-20 > 20

(Used for seizures)
Bilirubin Elevated hyperemibilirubin Kernicterus

(Waste product from the breakdown of 10-20 ● Bilirubin > 20; crosses BBB in CSF-
RBCs (only tested in NEWBORNS on the Toxic > 20 invaded brain causes aseptic
NCLEX) encephalitis meningitis > death
Hospitalized: 14-20 Opisthotonos
Normal in Newborn <10 ● Position of hyperextension seen with
Total bilirubin: 0-0.1 mg/dL kernicterus
Direct bilirubin: 0-0.3 mg/dL ● Arcing due to bili irritation in the brain
Indirect bilirubin: 0-0.3 mg/dL ● Place this child on their side
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Toxicity Symptoms:
● Lithium: heighten reflexes, seizures, agitation, slurred speech, kidney failure, rapid HR, hyperthermia,
uncontrollable eye movement, low BP, confusion, coma, delirium
● Digoxin: lack of appetite, nausea, vomiting, diarrhea, headache, confusion, anxiety, hallucinations,
restlessness, weakness, depression, blurred vision, seeing halos around bright objects, irregular
heartbeats and palpitations
● Aminophylline: seizures, increased appetite and thirst, palpitations, rapid or irregular HR, muscle
twitching, confusion, hallucinations, sweating, irritability, restlessness
● Dilantin: fast uncontrollable eye movements, double vision, dizziness, drowsiness, confusion, slurred
speech, nausea and vomiting, decreased appetite, decreased activity, abdominal bloating
DUMPING SYNDROME vs. HIATAL HERNIA

Hiatal Hernia Dumping Syndrome
(2 chambered stomach) (Speed Issue)
(Direction issue)
Definition ● Regurgitation of acid into esophagus, ● Post op gastric surgery complication in which
because upper stomach herniates gastric contents dump too quickly into the
upward through the diaphragm duodenum
● Gastric contents move in the wrong ● Gastric contents move in the correct (DOWN)
direction (UP instead of DOWN) direction direcion at the wrong (TOO FAST) rate
at the correct rate
Signs & Upper GI s/s: Lower GI s/s:

Symptoms ● Indigestion ● Acute lower abdominal distress: diarrhea,
● Heartburn cramping, gas, abdominal pain, guarding, splinting
● GERD (happens when you lie down after rigidity, distension
eating) ● Drunk (look), all blood going to gut not brain
● Chest pain (cerebrally impaired); confused
● Shock: blood in parasympathetic system;
pale/cold/clammy skin, ↓ BP, rapid pulse
● Hypoglycemia
Treatment 1. Stomach → empty faster 1. Stomach → empty slower

2. HOB during and 1 hour after meals: 2. HOB during and 1 hour after meals: Low HOB
Raise HOB (high fowler's) (head low and turned to the side)
3. Amount of fluids with meals: High fluids 3. Amount of fluids with meals: Low/Restricted fluids;
4. Carb content of meals: High carbs (↓ fluids in between meals
protein) 4. Carb content of meals: Low carbs (↑ protein)
ELECTROLYTES
**Kalamias do the SAME AS the prefix, except for heart rate & urine output!!
● Normal range: 3.5-5 mEq/L
● HYPERkalemia signs and symptoms:
○ Brain→ irritability, restlessness, agitation
○ Lungs→ tachypnea
○ Heart→ low heart rate, peaked T waves, ST elevation
○ Urine→ oliguria
○ Bowel→ diarrhea, borborygmi
○ Muscles→ spasticity
○ Reflexes→+3/+4, clonus (muscle spasm)
○ ↓ HR ↓ UO
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● HYPOkalemia signs and symptoms:
○ Brain→ lethargy
○ Lungs→ bradypnea
○ Heart→ tachycardia
○ Urine →polyuria
○ Bowel→ constipation, ileus; muscles→ flaccidity
○ Reflexes→ +1/+2
○ Cushings: immunosuppressed (needs PRIVATE room) (aldosterone;→ retain sodium &
water; low on potassium)
○ ↑ HR ↑ UO
**Calcemias do the OPPOSITE AS the prefix... (if it skeleton or nerve, blame it on calcium!)
● Normal range: 8.5-10.5 mg/dL
● HYPERcalemia signs and symptoms:
○ Brain → lethargy
○ Heart→ bradycardia
○ Bowel→ constipation
○ Muscles→ flaccidity
○ Reflexes: +1/+2
● HYPOcalemia signs and symptoms:
○ Urine→ polyuria
○ Bowel→ diarrhea
○ Muscles→ spasms
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○ Two signs of neuromuscular irritability associated with hypocalcemia:
■ Chvostek sign:
● When you touch their CHEEK, they go into a spasm of the face (neuromuscular
irritability associated with a LOW calcium)
■ Trousseau sign:
● When you put a blood pressure cuff on, blow it up & they go into a spasm of the
hand.
**Magnesiums do the OPPOSITE AS the prefix

● Normal range: 1.5-2.5 mEq/L
● HYPERmagnesemia signs and symptoms:
○ Brain→ lethargy
○ Heart→ bradycardia
○ Bowel→ constipation
○ Muscles→ flaccidity
● HYPOmagnesemia signs and symptoms:
○ Urine→ polyuria
○ Bowel→ diarrhea
○ Muscles→ spasms
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If symptoms involve nerve or skeletal muscle, pick Calcium. For any other symptoms, pick potassium
(generally anything affecting BP)
● In a tie ⇒ DON’T pick Magnesium
● Example: Which electrolyte imbalance causes diarrhea? Hyperkalemia, hypokalemia, hypocalcemia,
hypomagnesemia
○ Symptom is up so find something that causes stuff to go up
○ Potassium do the same as prefix → hyperkalemia = diarrhea; hypokalemia ≠ diarrhea
○ Calcemias do the opposite as prefix → hypocalcemia = diarrhea
○ Magnesiums do the opposite as prefix → hypomagnesemia = diarrhea
○ TIE: hyperkalemia, hypocalcemia, hypomagnesemia
■ Don’t pick magnesium
■ Diarrhea is not skeletal or nerve ≠ calcium
■ Blame it on high potassium
*Sodium
● Normal range: 135-145 mEq/L
● HYPERnatremia: DEHYDRATION
○ Fluid volume deficit, *DKA*, DI, HHNK
○ Signs and symptoms: p oor skin turgor, dark urine, hot dry flushed skin, increased urine specific
gravity, weak thready pulse
○ Give fluids
● HYPOnatremia: OVERLOAD
○ *Fluid volume excess*, SIADH
○ Signs and symptoms: crackles, distended neck veins, increased weight, edema
○ Fluid restriction, give Lasix
**The earliest sign of any electrolyte disorder is numbness and tingling (paresthesias).
● Circumoral paresthesias: numbness and tingling around the lips
The universal sign/symptom of electrolyte imbalance is muscle weakness (paresis)!!!
26
ELECTROLYTE TREATMENT: (boards should only test potassium)
● HIGH potassium (will stop your heart) Rules for Potassium:
○ NEVER push IV!
○ NEVER more than 40 of K per liter of IV fluid
■ If more than 40, question & clarify with DOC first!
○ HIGH POTASSIUM = worst electrolyte imbalance! *can STOP heart!*
■ So, how do we lower potassium?!?!
● Fastest way →Give D5W with REGULAR insulin “K enters early”
○ Drive potassium into the cell & out of the blood (not a permanent fix)
○ Good: it works fast
○ Bad: it doesn’t last long. Over the next 8 hours, the potassium will
leak back into the blood
● Kayexalate “K exits late” (switch the potassium with sodium)
○ Puts the drug in the gut and is full of Na (oral or rectal administration); As
it sits in the gut, Na is picked up by the bloodstream. To maintain
equilibrium, potassium has to be kicked out of the blood and into the gut.
When you defecate the kayexalate, it is full of potassium.
○ Blood starts out high in potassium but ends up high in sodium
■ They become dehydrated ⇒ give fluids
○ Good: gets rid of high potassium for good
○ Bad: takes a long time to work
● Give both simultaneously!!
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7. Endocrine Overview
*Thyroid
● HYPERthyroidism: “ hyper metabolism”
○ Signs and symptoms:
■ Weight loss, high pulse & BP, irritable, agitation, warm, heat intolerance, cold
tolerance, excitable, restlessness, exophthalmos (bulging eyes)
○ *Graves Disease (literally run self into the grave)
■ The problem is hyperthyroidism
■ Treatments:
● Radioactive iodine
○ KNOW: patient needs to be by themself for 24 hours (restriction of
visitors); after 24 hours they can have visitors
○ Be really careful with their urine (flush 3 times!) If the urine is spilled, they
must call the hospital hazmat team!! Only RISK to the nurse is the
patient’s urine (how the radioactivity is excreted!)
● PTU (propylthiouracil): *Puts Thyroid U
nder*
○ CANCER drug! KNOW: that it is an IMMUNOsuppressant
○ Monitor WBC Surgical removal can cause agranulocytosis (↓ WBC)
○ Education: isolation, wear mask, no kids
● Surgical removal
○ Thyroidectomy (remove the thyroid; most common way used!)
■ TOTAL (complete)
● Need lifelong T3, T4 hormone replacement
● At risk for hypocalcemia because they are at risk of losing
the parathyroid gland
○ S/S of hypocalcemia: tetany, irritability, spasm,
paresthesia (earliest sign), etc.
■ SUBTOTAL (partial)
● At risk for thyroid storm
● S/S of thyroid storm:
○ Very high fever > 104oF
○ Very high HR ~180-200s
○ Very high BP (stroke level, ~200/180s)
○ Psychotic delirium *life threatening priority*
● Thyroid storm = medical emergency (can cause BRAIN
damage!!!), basically frying your brain to death with
hypoxia
● Treatment for Thyroid Storm:
○ Treatment focuses on saving the brain until they
come out of it
○ OXYGEN per mask @ 10L!!!
○ BEST way to get temp down:
■ First: ice packs
■ Best: cooling blanket
○ FYI: If it’s a sequence question: oxygen, ice packs,
cooling blanket.. NEVER, EVER leave patient!
○ DO NOT USE TYLENOL - it works in the
hypothalamus and isn’t going to work at this time.
○ Wait out: either they come out of it or they will die
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● **Post OP RISKS:
○ 1st 12 hours: priority = airway & hemorrhage
○ 12-48 hours:
■ TOTAL: Tetany (muscular spasms in larynx which can cut off the
airway) due to low calcium
■ SUBTOTAL: Thyroid ST ORM!
○ 48-72 hours: Infection
■ FYI for INFECTION: NEVER choose infection as a PRIORITY in
the first 72 hours for anything!!! ONLY CHOOSE it after the first
72 hours!!!
● HYPOthyroidism *hypo metabolism*
■ Obesity, heat tolerance, cold intolerance, sluggish, decreased BP, bradycardia,
hair and nails are brittle
○ Name of disease: Myxedema
○ Treatment: give them thyroid hormone pills; Synthroid (levothyroxine)
○ *CAUTION!!* DO NOT sedate these patients; can put them in a coma
■ Example: What pre-op order would you question? AMBIEN @ HS..
■ If the patient is supposed to be NPO → make sure you question that they still get their
morning pill!! (they NEED it! NEVER hold your thyroid pills unless you have
EXPRESS orders to do so).
*ADRENAL CORTEX Diseases (diseases that start with A or C)

● ADDISONS:
○ UNDER secretion of the adrenal cortex (too little)
■ HYPERpigmented (3-4 shades darker than before)
■ Does NOT adapt to stress:
● When you are under stress, there is a threat to your brain. The purpose of the
stress response is to perfuse the brain with blood and give the brain glucose.
● These people can’t do this; glucose & BP goes down ⇒ go into shock!
○ Anything from a tooth filling at the dentist or a minor fender bender can
cause these.. people to stress out & die.. TICKING TIME BOMB!
○ *ADDISONS is one of the RAREST endocrine disorders*
■ Example: for every 600 CUSHING'S patients, there’s 1 ADDISON'S patients..
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■ *JFK had this dx; so when he was shot (even if it was in his shoulder & not his skull),
there was never any chance for survival*
○ Treatment:
■ Glucocorticoids (steroids; all end in “sone” ex: prednisone, dexamethasone &
hydrocortisone..
■ Remember: ADDISON'S “ADD a SONE”!!
● Cushing’s Syndrome
○ OVER secretion of the adrenocortex (cushy bank account = more money!)
○ **Signs and symptoms (KNOW!!):
■ Also it the side effects of steroids
■ Puffy moon face, hirsutism (excess hair on the body), trunkal obesity (big body),
gynecomastia (female breasts on men), buffalo hump (on back), skinny arm & legs
(muscles waste away), retain sodium & water/ losing potassium, striae (stretch marks),
easy bruising, ↓ bone density
■ Example: “I’m mad; I have an infection”; grouchy/irritable & immunosuppressed;
Practice drawing CUSHMAN!!
■ HIGH glucose *most important to remember!!* (hyperglycemic!!)
○ Treatment:
■ ADRENALectomy (bilateral) → steroid replacement therapy
● Need AccuChecks every 6 hours
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INFECTIOUS DISEASE & TRANSMISSION BASED PRECAUTIONS 4 types... STANDARD/UNIVERSAL:
CONTACT:
● For anything enteric (fecal/oral, caught from intestines), C. diff,cholera, shigellosis, rotavirus,
distentary
● Herpes
● Hepatitis A
● Any staph infections (MRSA)
● RSV (however it is transmitted via droplet),
● PRIVATE ROOM IS PREFERRED (same disease can be put in the same room; if suspected do not
put them in the same room > have to be cultured first).. GLOVES, GOWN, HAND WASHING,
DISPOSABLE SUPPLIES, DEDICATED EQUIPMENT
DROPLET:
● All viruses (bugs that travel 3 feet on large particles)
● Meningitis
● All Influenzas (DTaP, Pertussis, Hib, Mumps)
● PRIVATE ROOM IS PREFERRED, MASK, GLOVES, HAND WASHING, PATIENT WEARING
MASK - WHEN LEAVING ROOM, DISPOSABLE SUPPLIES
AIRBORNE:
● Measles
● TB (transmitted via droplet)
● Chicken pox (Varicella)
● SARS (Severe acute respiratory system)
● PRIVATE ROOM REQUIRED, MASK, GLOVES, HAND WASHING, SPECIAL FILTER MASK
(only for TB; N95), PATIENT WEARING MASK - IF LEAVING ROOM, NEGATIVE AIR FLOW
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**NCLEX TIP: PPE:
● Unless otherwise specified, assume that PPE includes gown, goggles, mask and gloves
● The proper place for putting on (donning) PPE is outside the room
● The proper order for donning PPE is:
○ Put on gown
○ Put on mask
○ Put on goggles
○ Put on gloves
● The proper place for removing (doffing) PPE is inside the room
● The proper order for removing PPE is:
○ Gloves
○ Goggles
○ Gown
○ Mask → need to take mask off outside so you don’t breath in contaminated air
● In airborne precautions only, the mask is removed outside of the room
Hand Washing and Gloving

Handwashing Scrubbing
Position Hands below elbows Elbows below hands
Length Seconds Minutes
Handles Yes, sink with handles No, sink with handles
When Upon entry and leaving room, before and after When patient is immunosuppressed for any
gloving, when hands are visibly soiled reason
Use Soap and water Something with chloro in it
Use an Alcohol-Based Solution:

● On entering or leaving a room
● Before putting on gloves, after taking off gloves
● Cannot → after soiled hands
What about after using the restroom? → must use soap and water
● Dry from cleanest (hand) to dirtiest (elbow)
● Turn water off with a new paper towel
Sterile Gloving
● Glove dominant hand first
● Grasp outside of cuff
● Touch only the inside of glove surface
● Do not roll cuff
● Fingers inside of second glove cuff
● Keep thumb abducted back
● Only touch outside surface of glove
● Skin touches inside of glove
● Outside of glove only touches outside of glove
● Remove glove to glove, skin to skin
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INTERDISCIPLINARY CARE
● Identifying which patients need interdisciplinary care...different than prioritizing → who would most
benefit from a team working together on their care
● Patients who DO NOT need interdisciplinary care: patients who need or have multiple doctors
● Patients who DO need interdisciplinary care:
○ Major criteria
■ Patients with multi-dimensional needs
● For example:
○ Physical
○ Psychological
○ Social
○ Spiritual
○ Intellectual needs
■ Patients who need rehabilitation
○ Minor criteria (choosing between patients)
■ A patient whose current treatment is ineffective
■ A patient who is preparing for discharge
LAMINECTOMY:
● A surgery that creates space by removing the lamina - the back part of the vertebra that covers your
spinal canal.
○ Also known as decompression surgery, laminectomy enlarges your spinal canal to relieve
pressure on the spinal cord or nerves.
○ Lamina = vertebral spinous processes (posterior)
○ Ectomy = removal
● WHY do you do this??
○ RELIEVE NERVE ROOT COMPRESSION
● S/S of nerve root compression:
■ Pain (usually distal extremities)
■ Paresthesia (numbness & tingling)
■ Paresis (muscle weakness)
● MOST IMPORTANT thing to pay attention in any NEURO question = LOCATION!
○ The location will determine the symptoms, prognosis, and treatment
○ 3 locations for laminectomy:
■ Cervical (neck) → innervates diaphragm and arms
■ Thoracic (upper back) → cough & bowels
■ Lumbar (lower back) → bladder & legs
● Pre-op Cervical Laminectomy
○ Cervical spine innervates diaphragm and arms!
○ Most important assessment:
■ 1st → Breathing
■ 2nd → how are arms functioning
● Pre-op Thoracic Laminectomy
○ Thoracic innervates abdomen and bowel functions
■ Cough mechanism and bowel function
● Pre-op Lumbar Laminectomy
○ Innervates bladder and legs
■ Bladder retention and leg function
● POST op Laminectomy Care
○ #1 post-op answer on NCLEX with spinal cord = LOG ROLL (move spine in one piece)
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○ Specific “activity”/mobilization strategy post-op:
■ Do NOT dangle them (sit on the edge of the bed)
■ Do NOT sit for longer than 30 minutes
● Post Op order to question: Up in chair for 1 hour or longer
■ They may walk, stand & lie down without restriction
● POST op COMPLICATIONS (depends on LOCATION!!)
○ Cervical: trouble breathing after surgery
■ #1 complication: PNEUMONIA
○ Thoracic: trouble with coughing
■ #1 complication: ASPIRATION PNEUMONIA & ileus (because bowels won’t work)
○ Lumbar:
■ #1 complication: urinary retention & problems with the legs
● ANTERIOR THORACIC laminectomy:
○ From front → through the chest → to the spine
○ Will have a CHEST TUBE (pneumohemothorax)!!
○ But no others will have a chest tube...
● Laminectomy with FUSION:
○ Involves taking a bone graft from the iliac crest (most common site) and fuse them together
○ So, there will be 2 incisions → spine & hip
■ Most pain → HIP ☹(causes most problems)
■ Most bleeding & drainage → HIP
● Will have a JP (Jackson-Pratt) drain
■ HIGHEST risk for INFECTION → 50/50 equal SPINE and HIP
■ HIGHEST risk for REJECTION → SPINE
○ Surgeons are using cadaver bone from bone banks. Why?
■ So don’t have to do grafts, reducing rejection and infection rate. Bone has decreased
protein with antigens and won't be as easily rejected. Decrease pain in patients post op
as well.
● Discharge TEACHING:
○ Temporary restrictions = normally always for 6 weeks
■ Do NOT sit longer than 30 minutes
■ Lie flat & log roll
■ NO driving
■ Do NOT lift anything more than 5 lbs (gallon of milk)
○ Permanent restrictions =
■ NEVER pick up object by bending at the waist; lift with the knees!!
■ Cervical laminectomies can NEVER lift anything over your head (for life!)
■ NO mountain biking, jerky moving ride (roller coasters), horseback riding, etc.
Remember: MOST IMPORTANT thing to pay attention to in *any* NEURO question = LOCATION!
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8. Lab Values
**Must know and also how to PRIORITIZE them!!**
● A= ABNORMAL ! Do Nothing
○ A = LOW priority
● B= BE CONCERNED ! Assess/Monitor
○ B = LOW priority, but be concerned (watch them)
● C= CRITICAL ! Do Something
○ C = HIGH priority; critical/do something!! *you CAN leave the bedside*
● D = DEADLY DANGEROUS ! Do Something NOW
○ D = HIGH priority; extremely critical!! *you can NOT leave the bedside*
● MEMORIZE the 5 D’s!!! (the 5 you really NEED to KNOW!!) HIGHEST PRIORITY PATIENTS
○ pH in the 6s
○ Potassium in the 6’s
○ Co2 in the 60s
○ O2 in the 60’s
○ Platelet count LESS than 40,000
● LEARN all the C’s & what to do!!! (about 8-10)
● When should you call the rapid response team?
○ When the patient is symptomatic
○ Assess them and then call
CREATININE (serum):
● BEST factor to determine RENAL function
● Normal Range: 0.6-1.2
● Elevated: Level A
○ If elevated it's abnormal but not too worrisome (jut mean kidney are failing)
○ *FYI* the only time you should contact the DOC because of a HIGH level creatinine, is if the
pt is going for a test/procedure (the next morning) that involves a DYE; but it is not priority to
let them know (it can wait until 6am/7am).
INR:
● Monitors coumadin therapy (Anticoagulant)
● Therapeutic level: 2-3
○ ↑ INR = bleeding risk
● Level C: level > 4 (critical)
○ Do something:
■ (1) always HOLD,
■ (2) ASSESS (focuses assessment on area)
■ (3) PREPARE to administer Vitamin K
■ (4) CALL doc/respiratory/etc.
■ Example: (click & drag)... level of 4.7 = HOLD coumadin, ASSESS for bleeding,
PREPARE to give vitamin K, CALL doc! -sometimes there’s nothing to HOLD, so jump
to ASSESS.. sometimes there’s nothing to PREPARE, so jump to CALL - but you
should always go through the process in your mind, so you don’t miss a step.
POTASSIUM:
● An indicator that something is wrong
● Level C: Hypokalemia <3.5
○ LOW:
■ ASSESS heart (may include EKG)
■ PREPARE to administer potassium
■ CALL doc.
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● Level C: Hyperkalemia 5.4-5.9
○ HIGH:
■ HOLD all potassium
■ ASSESS the heart
■ PREPARE (kayexalate, D5W & regular insulin)
■ CALL doc.
● Level D: > 6 Cardiac Danger Zone
○ Deadly serious; pt could DIE, in like the next 2 minutes
■ HOLD all potassium
■ ASSESS the heart
■ PREPARE kayexalate, D5W & regular insulin
OU stay with your PT***
■ CALL doc ***STAT!!! get everyone involved & Y
pH:
○ As pH does, so does my patient
● K+ can increase which could stop the heart
● Level D: pH in the 6’s (ex: 6.8)
○ ASSESS the VITALS immediately
○ CALL doc & get them there STAT!! Can also call rapid response team
● Don’t give sodium bicarbonate to acidotic patients, treat underlying cause of the acidosis
BUN (blood urea nitrogen):

● Nitrogen waste products in the blood
● Normal Range: 8-25
● Level B: elevated
○ If, HIGH, no BIG deal - ASSESS pt for DEHYDRATION
○ *FYI* If they give you an elevated blood value & you have NO clue what’s going on; & they
ask for what would you assess them; DEHYDRATION is a good answer.
Hemoglobin:
● Level B: 8-11
○ ASSESS for anemia (bleeding or malnutrition)
● Level C: < 8
○ Do something!
■ ASSESS for bleeding,
■ PREPARE to administer BLOOD
■ CALL doc.
Bi-carb (HCO3):
● Chemical buffer that keeps the pH of blood from becoming too acidic or too basic
● Level A: Abnormal, don’t worry!
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CO2:
● Carbon dioxide; getting from an arterial blood gas
● Normal range: 35-45
● Level C in the 50s:
○ *Talking about people WITHOUT COPD!!*
○ ASSESS respirations,
○ PREPARE: have patient do pursed lip breathing
■ Pursed lip breathing (PLB) is the breathing technique that consists of exhaling through
tightly pressed (pursed lips) and inhaling through nose with mouth closed.... This should
FIX problem; so you shouldn’t have to CALL doc.
● Level D: in the 60’s
○ Respiratory FAILURE
■ ASSESS respiratory status
■ PREPARE for INTUBATION/VENTILATE
■ CALL respiratory therapy first, then CALL the doc. (YOU stay with YOUR pt!!!)
Hematocrit:
○ 3x the hemoglobin; 12-18
● Level B: elevated hematocrit
○ ASSESS for dehydration
pO2:
● From arterial blood gas; not pulse ox!
● Level C: 70-77 Respiratory insufficiency
○ ASSESS for respiratory status
○ Give them OXYGEN!! (do not need an order)
● FYI: when a pt is HYPOXIC: which rate increases first? respiratory rate or heart rate?
○ Heart rate will increase first then the respiratory rate will go up
● FYI: if you ever work CORONARY care, what are the 2 most common causes of episodic
tachycardia in heart pt’s? HYPOXIA & DEHYDRATION
● Level D: < 60s Respiratory failure
○ Give oxygen
○ ASSESS respiratory status
○ PREPARE for INTUBATION/VENTILATE
○ CALL RT and doc
○ Example: (click & drag question): THROW on O2, ASSESS, PREPARE to intubate/ventilate &
then call respiratory/doc..
**NCLEX TIP: 80% of the time, you always assess before you do anything.. 20% of the time you need to
hold something before you assess.
● An example where this is not true, if if you had a blood transfusion going on and the patient was
complaining of itching... You would STOP the infusion & then assess the pt!
● ASSESS before you DO, UNLESS delaying DOING puts your pt at higher risk!
● BEST vs. FIRST question... BEST: administer O2, FIRST: raise head of bed
○ If you have to pick between doing two things: do the position thing first than the other
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O2 Sats:
● Level C: Anything < than 93 (for NCLEX!!)
○ In real life, be HAPPY with 88 & >!!
○ ASSESS respirations & throw on O2!
○ For PEDIATRICS; FREAK out if the kid goes BELOW 95!!!
● FYI: What invalidates for SaO2?
○ Anemia will falsely elevate SaO2
○ Dye procedure in the last 48 hours
■ *These patients will look better than they actually are according to their SaO2
BNP:
● Brain Natriuretic Peptide → BEST indicator for CHF; chronic condition
● Normal Range: < 100
● Level B: elevated
Sodium:
● Level B: abnormal
○ ASSESS!
■ HIGH = ASSESS for dehydration
■ LOW = ASSESS for overload
● Level C: *If the question says that the level is abnormal & there is a change in the LOC
○ Safety Issue
WBC:
● Normal Range:
○ *Total WBC: 5,000-11,000
○ *ANC (absolute neutrophil count): NEEDS to be ABOVE 500
○ *CD4 count: NEEDS to be ABOVE 200
■ When CD4 is below 200 → this is when HIV goes into AIDS
● Level C: when all of these values are below normal
○ ASSESS for signs of infection & place them on NEUTROPENIC precautions!
■ Neutropenic Precautions:
● Strict handwashing
● Shower BID with antimicrobial soap
● Avoid crowds
● Private room
● Limit number of staff entering the room
● Limit visitors of healthy adults
● No fresh flowers or potted plants
● Low bacteria diet:
○ No raw fruits, vegetables, salads
○ No undercooked meat
● Do not drink water that has been standing longer than 15 minutes
● Vital signs (temp) every 4 hours
● Check WBC (ANC) daily
● Avoid use of indwelling catheter
● Do not reuse cups..must wash in between use
● Use disposable plates, cups, straws, plastic knife, fork, spoon
● Dedicated items in room: stethoscope, BP cuff, Thermometer, Gloves
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○ Terminology:
■ High WBC count → Leukocytosis
■ Low WBC count → Leukopenia, Neutropenia, Agranulocytosis, Immunosuppression,
Bone marrow suppression
Platelets:
● Thrombocyte clotting cell
● Normal Range: 150,000-400,000
● Level C: < 90,000
○ ASSESS for bleeding
○ Bleeding precautions
○ CALL doc
● Level D: < 40,000
○ Could spontaneously hemorrhage to death
○ ASSESS for bleeding
○ Bleeding precautions
○ PREPARE for transfusion
○ CALL doc
● Bleeding Precautions (Thrombocytopenic Protocol):
○ No unnecessary venipuncture-injection or IV. Use small gauge
○ Handle patient gently; use draw sheet
○ Use electric razor
○ No toothbrush or flossing
○ No hard foods
○ Well fitting dentures (no rub)
○ Blow nose gently
○ No rectal temp, enema, suppository
○ No aspirin
○ No contact sports
○ No walking in bare feet
○ No tight clothes or shoes
○ Use stool softener. No straining
○ Notify MD of blood in urine, stool
RBC:
● Normal Range: 4-6 million
● Level B: abnormal count
○ Check for bleeding
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9. Psych Drugs
-Know generic names of drugs!!
**ALL psych drugs cause LOW BP & WEIGHT CHANGES
● The vast majority will cause weight gain, however, some other meds (ex: Prozac) can cause weight
LOSS!
Phenothiazines:
● 1st generation/typical ANTIpsychotics
● They all end in “zine”
○ Example: Thorazine, Compazine
● Very potent
● Immediate onset
● Actions:
○ Does not cure disease. Reduces symptoms
○ Large doses: Psychotic symptoms (Hallucinations)
○ Small doses: Nausea/Vomiting
○ They are considered MAJOR TRANQUILIZERS
○ *Aminoglycosides are to antibiotics, like phenothiazines are to tranquilizers* = they’re both the
BIG GUNS!
● Side Effects:
○ A = Anticholinergic (dry mouth) *Nursing dx: risk for injury*
○ B = Blurred vision *Nursing dx: risk for injury*
○ C = Constipation
○ D = Drowsiness
○ E = EPS (extrapyramidal symptoms); like Parkinson's *Nursing dx: risk for injury*
○ F = FPhotosensitivity a
○ G = AGranulocytosis (LOW white count; immunosuppressed)
○ TOXIC side effect: HOLD & CALL doc!!!
● Nursing Care:
○ Treat side effects. #1 nursing diagnosis is safety
● “Decanoate” or D (written after a medication name; ex: thorazine D)
○ It is LONG acting
■ Sometimes it works for 2 weeks; sometimes it works for a month
○ Given IM form to noncompliant pt’s; usually court ordered.
Tricyclic antidepressants:
● Old class; grandfathered into the NSSRI class)
● MOOD elevators used to treat depression
● Examples: elavil, tofranil, aventyl, desyrel
● Side Effects:
○ A = Anticholinergic (dry mouth)
○ B = Blurred vision
○ D = Drowsiness
○ E = Euphoria
● The pt must take these for 2-4 weeks before they see beneficial effects!
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Benzodiazepines:
● Antianxiety meds... considered to be MINOR TRANQUILIZERS
● They always have “zep” in the name
○ Examples: prototype → diazepam (valium), lorazepam
● Indications:
○ Can be used as a pre-op to induce anesthesia
○ Can be used as a muscle relaxant
○ Can be used for alcohol withdrawal
○ Can be used to help with seizures (especially status epilepticus)
○ Can be used to help a pt fight a ventilator (relaxes them)
● They work quickly
○ But you must not take them longer than 2-4 weeks.
○ Keep on Valium until Elavil kicks in
● What is the relationship between a minor tranquilizer and an antidepressant?
○ One takes 2-4 weeks to work and can be on the drug for the rest of your life; the other one
works right now but can’t be on it longer than 2-4 weeks.
○ Example: When someone comes anxiously depressed, they are put on both.The minor
tranquilizer will help them feel better right now. The antidepressant will kick in 2-4 weeks and
then they are taken off of the minor tranquilizer. They will go home on the antidepressant.
○ Analogy: Heparin is to Coumadin as a tranquilizer is to an antidepressant.
■ Heparin and tranquilizers work fast but can’t be on them for very long. Coumadin and
antidepressants take a while to work but can be on them for a long time.
● Side Effects:
○ B = Blurred vision and Bladder retention
○ D = Drowsiness
● #1 Nursing diagnosis is safety, injury
MAOIs (monoamine oxidase inhibitors):

● Antidepressants
● Depression is thought to be caused by a deficiency of norepinephrine, dopamine, and serotonin in the
brain.
○ Monoamine oxidase is the enzyme responsible for breaking down norepinephrine, dopamine,
and serotonin.
○ MAO inhibitors prevent the breakdown of these neurotransmitters and thus restore more normal
levels and decrease depression.
● NOT really given anymore; except with the VETERAN hospitals (they are super cheap; they cost only
pennies)
● Drug names: Marplan, Nardil & Parnate
● Side Effects:
○ D = Drowsiness
● Interactions: #1 thing that NCLEX tests: PT teaching!!
○ To PREVENT severe acute, sometimes fatal HYPERtensive (stroke) crisis:
■ The patient must avoid all TYRAMINES:
● Fruits and veggies (remember salad “BAR”)
○ AVOID:
■ Bananas
■ Avocados
■ Raisins (any dried fruits)
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● Grains: all okay except things made from active yeast
● Meats
○ No organ meats: liver, kidney, tripe, heart, etc
○ No preserved meats: smoked, dried, cured, pickled, hot dogs
● Dairy
○ Can have cottage cheese and mozzarella cheese
○ No aged cheese
○ No yogurt
○ Cannot eat brick cheese
● Other
○ No alcohol, elixirs, tinctures, caffeine, chocolate, licorice, soy sauce
○ Drug Interactions:
■ 1. Teach patient not to take OTC meds unless they are prescribed
Lithium:
● An electrolyte—notice –ium ending as in potassium, etc
○ Stabilizes nerve cell membranes
● Used to treat BIpolar disorder (decreases MANIA)
● Side Effects: 3 P’s
○ PEEing (Polyuria)
○ POOPing (Diarrhea)
○ Paresthesia (numbness & tingling)
■ Because the early sign of ALL electrolyte imbalance
■ YOU can still GIVE lithium with these S/S; just tell the DOC when they come in.
● TOXIC side effects:
○ Tremors, metallic taste, severe diarrhea or any other neuro signs besides paresthesia
● #1 Nursing Intervention: Increase fluids; keep hydrated
○ If the patient is sweating/manic →do NOT give them water; give Gatorade/POWERADE!
● Lithium is closely linked to SODIUM → Monitor sodium levels
○ For lithium to work, the SODIUM level must be normal.
■ LOW sodium makes lithium MORE TOXIC
■ HIGH sodium will make lithium ineffective
Prozac (Fluoxetine):
● It is an SSRI (antidepressant)
● Similar to Elavil (A tricyclic antidepressant)—same info
● Side Effects:
○ D = Drowsiness
○ E = Euphoria
● Prozac causes INSOMNIA
○ Give it before NOON; don’t give at BEDTIME
● When changing the DOSE in adolescents/young adults; watch for increased suicidal risk!
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Haldol (Haloperidol):
● *The ONLY MAJOR antipsychotic tranquilizer that CAN be given to pregnant women!*
● Like phenothiazines (1st generation/typical ANTIpsychotics)
○ Basically the same as Thorazine
■ Very potent
■ Immediate onset
● Has a “decanoate” form; LONG acting, IM injection
● Actions:
○ Does not cure disease. Reduces symptoms
○ Large doses: Psychotic symptoms (Hallucinations...
○ Small doses: Nausea/Vomiting
○ Major: Tranquilizers
● Side Effects:
○ A = Anticholinergic (dry mouth) *Nursing dx: risk for injury*
○ B = Blurred vision *Nursing dx: risk for injury*
○ D = Drowsiness
○ E = EPS (extrapyramidal symptoms); like Parkinson's *Nursing dx: risk for injury*
○ F = Fotosensitivity (photosensitivity) a
○ G = AGranulocytosis (LOW white count; immunosuppressed)
○ Teach patient to report sore throat and any S/S of infection to DR
● Nursing Care: treat side effects. Number one nursing diagnosis is safety.
NMS *MUST KNOW!!*

● Neuroleptic Malignant Syndrome is a life-threatening neurological disorder most often caused by an
adverse reaction to neuroleptic or antipsychotic drugs...
● Causes extremely HIGH fevers (pyrexia): 106-108oF.
○ Make sure that the dose for an ELDERLY pt is HALF the adult dose!!!
● Note: NMS can also cause anxiety & tremors; just like EPS (like Parkinson's)
○ NCLEX will test to see if you know the difference:
■ EPS = side effect (NO big deal)
■ NMS = medical EMERGENCY;
● Patient could die (HUGE big deal!)
● **TAKE a TEMPERATURE! *FEVER!!*
○ If 102 & above, call RAPID RESPONSE!
■ Safety CONCERNS related to the side effects
Clozapine (clozaril):
● **Do not confuse with Klonopin (Clonazepam)
● Prototype: original first Second Generation atypical antipsychotic
● NEW class for ZANIEs
○ It is meant to replace the ZINEs & haldol
● Used to treat SEVERE schizophrenia
● Advantage: it does not have side effects A, B, C, D, E, or F
● Disadvantage: it DOES have side effect → Agranulocytosis (worse than cancer drug in susceptible
patients)
○ For first month need WBC counts weekly. If WBC LOW STOP!
■ Nursing > Measuring WBC is a big deal!!
○ Agranulocytosis doesn’t always happen with everyone; so some people can take this drug &
some people can’t.
○ Trashes bone marrow
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*Geodon (Ziprasidone) has a BLACK BOX WARNING
● FATAL drug situation
○ It prolongs the QT interval & can cause sudden CARDIAC arrest ☹
○ *Do NOT use with patients that have heart problems
Tranquilizer class:
● 1st generation/typical ANTIpsychotics end in “-zine”
○ Old, Major
○ Thorazine, Compazine
● 2nd generation/atypical ANTIpsychotic end in “-zapine”
○ New, Major
● Minor tranquilizers end in “-zep”
○ Diazepam, Lorazepam (Benzodiazepines)
Zoloft (Sertraline):
● SSRI (like Prozac)
● Side Effects:
○ D = Drowsiness
○ E = Euphoria
● Causes INSOMNIA, but you can give it at bedtime
● BIG THING that NCLEX is testing: Interactions!!
○ *Cytochrome p450 system (in the liver) responsible for breaking down and deactivating the
drugs → Zoloft usually interferes with this system!
■ Can cause toxicity of other drugs so if they are taking other drugs with Zoloft, the doses
of the other medications should be lowered.
○ St. John’s wort ⇒ Serotonin Syndrome *deadly
■ Sweating
■ Apprehension → impending sense of doom
■ Dizziness
■ HEAD-ache
○ **Warfarin (Coumadin) ⇒ watch for bleeding (may need to lower warfarin dose)
■ When take Zoloft- warfarin and INR stays UP
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10. Maternity
-Be able to calculate a due date (Nagele’s Rule):
● First day of last menstrual cycle
● Add 7 days
● Subtract 3 months
● Add a year
-Total weight gain during pregnancy: 25-31 pounds

● Ideal weight gain: [Week of gestation] - 9 (+ a couple lbs)
○ If more than 3 lbs, you need to assess, something could be wrong
-Fundus:
● Top of the uterus; not palpable until week 12
● Fundus typically reaches the umbilical (naval) level at week 20-22
● 1st trimester (1-12 weeks): 1 lb/month weight gain, total: 3 lbs
○ Fundus not palpable. Mother is Priority
○ If you can palpate the fundus or she gains 10lb, she might have a hydatidiform mole, or not
really be in the 1st trimester
○ You can palpate the fundus at the end of the 1st trimester
● 2nd trimester (13 - 27 weeks): 1lb/week weight gain
○ Fundus at umbilicus or below it.
○ Mother is Priority
○ At 20-22 weeks the fundus is at the umbilicus
● 3rd trimester (28 - 40 weeks): 1lb/week weight gain
○ Fundus above umbilicus.
○ Baby is Priority
-Signs of pregnancy:
● 4 Positive Signs: Fetal skeleton on an X-ray; Fetal presence on ultrasound; Auscultation of the fetal
heart (doppler); Examiner palpate fetal movement/outline
● HR begins to beat at 5 weeks, but you can hear it at 8-12 weeks, and when the examiner palpates fetal
movement
● Quickening (when the baby kicks): 16-20 weeks
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● *NCLEX TIP: 3 Different Questions for OB Q’s:
○ “When would you first auscultate a fetal heart?” - 8 weeks
■ “First”: pick earliest part of range
○ “When would you most likely auscultate a fetal heart?” - 10 weeks
■ “Most likely”: pick mid part of range
○ “When should you first auscultate a fetal heart by?” - 12 weeks
■ “Should”- pick end of range
-Probable/Presumptive “The Maybes”:

● Positive Pregnancy Test
● Chadwick, Goodells, Hegar signs (Alphabetical in that order)
○ Chadwick: Cervical color change to cyanosis ($4 blue candle)
○ Goodells: Cervical softening (good when your cervix softens, 2 ll’s =2 month)
○ Hegar: Uterine softening (upside down g for 6 months)
-Patient Teaching:
● Come once/month until week 28 (3rd trimester)
● Week 28 → come once every 2 weeks until week 36
● Week 36 → every week until delivery until week 42.
● Hemoglobin will fall
○ Normal hemoglobin for females → 12-16
○ 1st trimester → can fall to 11 and be normal
○ 2nd trimester → can drop to 10.5 and be normal
○ 3rd trimester → can drop to 10 and be normal
○ Acceptably low can be as low as 9
● When does morning sickness start and how to treat it?
○ It happens during the first trimester
○ Treatment: eat dry carbohydrates (crackers) before getting out of bed and avoid having an
empty stomach
● When does urinary incontinence happen and how to treat it?
○ It happens during the first and third trimester
○ Not a problem during the second trimester because the baby is up high off the bladder
○ Treatment: void every 2 hours all the way through 6 weeks postpartum
● Dyspnea (difficulty breathing):
○ 2nd & 3rd trimester
○ Treatment: Tripod position ⇒ Feet flat, arms on table/knees leaning forward
● Back pain:
○ 2nd & 3rd trimester
○ Treatment: Pelvic tilt exercises
**NCLEX TIP: Pregnancy is a healthy state. If you don’t know the answer, think “What would be good for
anybody?” and that is usually the answer.
-Labor & Birth:

● Valid sign of labor: Onset of regular progressive contractions
● Dilation: Opening of cervix
○ 0-10 cm → 0 is closed, 10 fully dilated
● Effacement: Thinning of the cervix. From thick to 100%
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● Station: relationship of fetal presenting part to mom's ischial spine (tightest squeeze)
○ Negative station: above spine
■ Presenting part is above the tight squeeze (-1, -2) → BAD
○ Positive stations: below spine
■ Presenting part is below the tight squeeze (+1, +2) → GOOD
○ Engagement is station zero; at the ischial spine
● Lie: Relationship between the spine of mom & spine of baby

○ Vertex lie (longitudinal): Compatible for natural vaginal birth; uncomplicated
■ Mom’s spine and baby’s spine are parallel (Good)
○ Transverse lie (shoulder presentation): Trouble
● Presentation: Part of baby that enters the birth canal first

○ Most common is: ROA or LOA
-Stages of Labor:
Stage One:
● The purpose of uterine contractions in 1st stage: dilate & efface the cervix
○ Phase 1 (Latent):
■ Dilation: 0-4 cm
■ Contraction Frequency: 5 - 30 mins apart, lasts 15-30 secs
■ Intensity → mild
○ Phase 2 (Active):
■ Dilation: 5-7 cm
■ Contraction Frequency: 3-5 mins apart, lasts 30-60 secs
■ Intensity → moderate
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○ Phase 3 (Transition):
■ Dilation: 8-10 cm,
■ Contraction Frequency: 2-3 mins, lasts 60-90 secs
■ Intensity → strong
● **Only memorize phase 2. 1st 3 letters in latent tell u the order of phases**
● MUST KNOW!!!
○ Signs of uterine tetany/ uterine hyperstimulation/ stop Pitocin:
■ Contractions should not be longer than 90 seconds or c loser than every two
minutes!!
*NCLEX TIP: ****PAY ATTENTION TO THE Q: PHASES ARE NOT STAGES! ****
How to time contractions:

● Frequency ⇒ beginning of one contraction to the beginning of the next contraction (A → C)
● Duration ⇒ beginning to end of one contraction (A → B, C → D)
● Intensity ⇒ strength of the contraction; palpate with pad of fingers of one hand over the fundus
Complications:
● Painful back labor: LOP, ROP
○ Low priority
○ What do you do? Position than Push:
■ Position → knee chest: on hands and knees with butt and head up
● This brings the baby down off the sacrum and coccyx
■ Push → take fist & push into sacrum
● Provides counter pressure and relieves some pain
■
● Prolapsed Cord: Bad, OB emergency
○ When the cord is the presenting part, which wraps around baby’s neck,
○ High priority
○ What do you do? Push than Position:
■ Push head back up off the cord
● Keep your hand there until the baby is delivered
■ Position her in knee chest
● Interventions for all other complications of birth:
○ **LION → turn on left side, increase IV, O2, notify doc
○ In a crisis: if Pitocin is running, stop the Pitocin first! & then do LION*****
Pain MGMT:
○ Do not administer a systemic pain medication to a woman in labor IF the baby is likely to be
born when the pain med peaks. (Respiratory depression)
○ Example:
■ You have a primigravida at 5 cm who wants her IV push pain med. Will you give it to her
or not?
● Is it likely that she will deliver the baby in the next 15-30 minutes?
○ No → give her the pain med
■ You have a multigravida at 8 cm who wants her IM pain med. Will you give it to her?
● Is it likely that she will deliver the bay in the next 30-60 minutes?
○ Yes → do not give pain med
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FETAL HEART MONITORING
ALWAYS check FETAL heart rate!!

LOW fetal heart rate (under 110) → BAD ☹
● Treatment: LION (LEFT side, IV, O2, notify!)
● If Pitocin was running, stop it!
HIGH fetal heart rate (over 160) → OKAY

● NO big deal/document
🙂
● Take Mom’s temp (may have fever); nothing wrong with baby
LOW baseline variability → BAD ☹

● When fetal heart rate stays the same & does not change
HIGH baseline variability → OKAY 🙂

● When fetal heart rate is always changing → Good/document!
LATE decelerations → BAD ☹

● Heart rate slows down near the end or after a contraction
EARLY decelerations → OKAY 🙂

● Baby’s heart SLOWS before or at the beginning of a contraction → Fine/document!
VARIABLE decelerations → VERY BAD ☹

● Prolapsed cord
● Treatment:
○ Push head back up off the cord
■ Keep your hand there until the baby is delivered
○ Position her in knee chest
***Any position that starts with L, do LION, except variable (push position)***
● L’s and V’s = VERY BAD
● *ALWAYS Check fetal heart rate*** always a good choice on test
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Stage #2 Delivery of the BABY!!!
● The purpose of uterine contractions is to push the baby out
● Order:
a. Deliver the head
b. Suction the mouth than the nose
c. Check for nuchal cord (around the neck)
d. Deliver the shoulders than the body
e. Baby must have ID band on before it leaves the delivery area
Stage #3 Delivery of the PLACENTA

● The purpose of uterine contractions is to push the placenta out
○ Make sure it is INTACT
● Make sure the cord has 3 vessels (AVA → 2 arteries & 1 vein)
Stage #4 Recovery
● The purpose of uterine contractions is to contract the uterus to stop bleeding
● Postpartum technically begins 2 hours after the placenta comes out
● *4 things you do, 4 times per hour in the 4th stage!*
a. VITAL signs:
■ Looking for signs and symptoms of SHOCK
● Pressures go DOWN, rates go UP, pale, cold & clammy
b. Check the FUNDUS
■ If it’s boggy → massage it
■ If it’s displaced → you void or catheterize!
c. Check the PADS
■ 100% saturated in 15 minutes or less, she is bleeding excessively
■ If 98% saturated it’s okay
■ She should not soak a pad in one hour or less due to risk of hemorrhage.
d. ROLL her over (check for bleeding underneath her)
Postpartum ASSESSMENT:
● Done every 4-8 hours
○ B: Breasts
○ U: Uterine fundus**
■ Needs to be FIRM;
● If boggy, massage! needs to be midline
● If not, void/cath them
● Height to fundus related to the belly button:
○ Fundal height = days postpartum
■ 4th postpartum day → 4 below on the 4th day
○ B: Bladder
○ B: Bowel
○ L: Lochia** (vaginal discharge)
■ Rubra: 1st; red
■ Serosa: 2nd; pink
■ Alba: 3rd; white
■ Amount:
● 4”-6” on a pad/hours = okay...
● SATURATE a pad 15 mins or less = bad.
○ E: Episiotomy
○ H: Hemoglobin & Hematocrit
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○ E: Extremity check**
■ Pulses
■ Edema
■ Looking for thrombophlebitis
● Bilateral calf circumference measurements
○ A: Affect (emotions)
○ D: Discomfort
Normal Variations in the NEWBORN

● Caput succedaneum:
○ Crosses sutures (symmetrical)
■ Refers to the swelling, or edema, of a newborn's scalp soon after delivery.
○ It appears as a lump or a bump on their head. This condition is caused by prolonged pressure
from the dilated cervix or vaginal walls during delivery.
● Cephalohematoma:
○ Does not cross sutures (not symmetrical)
○ Is a traumatic subperiosteal hematoma that occurs underneath the skin, in the periosteum of
the infant's skull bone.
● Physiological vs Pathological Jaundice
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Milia:
Distended sebaceous glands which appear as tiny white
spots on baby’s face
Epstein’s pearls:
Small, white epithelial cysts on baby’s gums
Mongolian spots:
Bluish-black macules appearing over the buttox and/or
thighs of darker-skinned neonates
Erythema Toxicum Neonatorum:

Red papular rash on baby’s torso which is benign and
disappears after a few days
Hemangiomas:
Benign tumor of capillaries
Vernix caseosa:
Whitish, cheese-like substance which appears
intermittently over the first 7-10 days
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Acrocyanosis:
Normal cyanosis of baby’s hands and feet which appears
intermittently over the first 7-10 days
Nevus/Nevi:
Generic term for birthmarks
Nevus flammeus: nonblanchable port wine stain
Telangiectatic nevi: blanchable pink “stork bites”
OB Medications
● Tocolytics: stops labor
○ Terbutaline: causes maternal tachycardia
○ Magnesium Sulfate: HYPERmagnesemia
■ ↓ HR and BP
■ ↓ Reflexes
■ ↓ Respiratory Rate
■ ↓ LOC!
■ Parameters for titrating mag sulfate:
● Respirations ABOVE 12; it’s okay...
● Respirations BELOW 12; slow the mag down!
● Reflexes: we WANT +2.. if it’s +1; slow it down.. +3; speed it up.
● Oxytocics: stimulate & strengthen labor!
○ Oxytocin *Pitocin*
■ BIG thing to remember → it can cause uterine hyperstimulation
● Contractions lasting longer than 90 seconds & closer than every 2 minutes
● If you see this, back off your PICC!
○ Methergine: causes HIGH BP
○ Hemabate should not be given to a mother with asthma
FETAL LUNG MATURING Medications:

● Given to the baby to help their lungs mature faster
● Betamethasone (*steroid*)
○ It is given to the mother by IM before the baby is born
○ Can be repeated as long as the baby is in utero
● Survanta *Surfactant*
fter it is born
○ It is given to the baby a
○ It is given transtracheal (blown in through the trachea; nebulizer)
**The only antipsychotic pregnant women can get is Haldol**
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Medication HELPS & HINTS
● Humulin 70/30:
○ An insulin that combines the short action of regular human insulin (Humulin R) and the
intermediate action of Humulin N. N = 70% & R = 30%
● Drawing up insulin:
○ CLEAR before CLOUDY... “RN”; what we all want to be!!! ☺
clear = R, cloudy = N
○ Steps to draw up insulin:
■ Draw up the total dose in air
■ Put air in the “N” vial
■ Put air in the “R” vial
■ Draw up the “R” dose
■ Draw up the “N” dose
● Injections:
○ What size needle are you using?
■ The clue is in the abbreviation! Look at the first letter & then go find that number!
■ IM: 21 gauge/1 inch (1M- always pick the gauge/inch with the 1 in it)
■ Subcutaneous: 25 gauge/ 5/8ths (S looks like 5)
● Heparin vs Coumadin:
○ *Heparin -given IV or subQ
■ Works immediately
■ Can NOT be given for longer than 3 weeks (except for lovenox)
■ Antidote = protamine sulfate
■ Lab test that monitors: PTT (heparin = 7 letters; count on hand; 3 fingers left)
■ CAN be given to pregnant women
○ *Coumadin -given only PO
■ Takes a few days to a week to work
■ Can be given for the rest of your life
■ Antidote = vitamin K
■ Lab test that monitors: PT (INR) (coumadin = 8 letters; count on hand; 2 fingers left) -
■ CAN NOT be given to pregnant women
● K wasting / K sparing Diuretics
○ Any diuretic ending in X = X’s out K (waste) + Direril
○ All others spare K!
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● Muscle Relaxers
○ Baclofen and Flexeril are most tested**
■ When you’re on your Baclofen you are your “back loafin”
■ Flexeril, you flex your muscles
○ Side Effects:
■ Fatigue/Drowsiness
■ Muscle weakness
○ Teach:
■ When taking these:
● Don’t drink
● Don’t drive
● Don’t operate heavy machinery
PEDIATRIC TEACHING
*KIDS TOYS!!!* 3 questions to ALWAYS ask:
● Is it SAFE?
● Is it AGE APPROPRIATE?
● Is it FEASIBLE? (possible to do easily or conveniently)
○ FEASIBILITY consideration:
■ Could they do it? ex: Is swimming a good activity for a 13 year old?
● Safe → yes, Age appropriate → yes, Feasible for a kid in a body cast → NO!!
*SAFETY considerations:
● NO SMALL TOYS for children UNDER 4 (could put in mouth/aspirate)
● NO METAL (die-cast) TOYS if OXYGEN is in use → sparks!
● BEWARE of FOMITES (NON-living object that harbors microorganisms)
○ What toys are the worst for FOMITES? Stuffed animals
○ What toy is the best for FOMITES? Hard plastic toys/you can disinfect it!
○ *BEST toy for an IMMUNOSUPPRESSED child? HARD PLASTIC action figure!
*AGE APPROPRIATE considerations:

● Infant 0m-6m:
○ *BEST toy: musical mobile *stimulates motor & sensory skills*
○ 2nd BEST toy: SOFT & LARGE toys and books
○ Swim classes with parent
● 6m-9m: *working on object permanence*: they know it’s still there even though they can’t see it
○ Example: If they don't have object permanence and you put a toy under a blanket - they will
cry; if they have it: they know to lift the blanket & get it.
○ At this age, your “play” should be teaching them object permanence → that is their big task at
this time.
○ *BEST toy: cover/uncover toys: play PEEK-a-BOO; Jack-in-the-Box, etc.
○ 2nd BEST toy: window books, something large/hard; wood, metal or hard plastic
○ WORST toy: musical mobile; they can sit up/reach up and then can stranglate themselves ☹
● 9m-12m: *working on vocalization*:
○ *BEST toy: speaking toys/books; ex: “Talking” Woody (Toy Story!), Tickle Me Elmo, Teddy
Ruxpin, See & Say: “the COW says MOO”, etc.
○ They also need PURPOSEFUL ACTIVITY
■ **NEVER PICK THESE ANSWERS if the kid is UNDER 9m: build, sort, stack, make,
construct - why? PURPOSE words!!
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● Toddlers 1-3 years:
○ Best toy: PUSH/PULL; examples: lawn mower, baby stroller
■ *Work on GROSS MOTOR skills: running, jumping
■ NO finger dexterity yet
● They can’t color, use scissors, etc.
● Finger painting → yes, because they can use their HAND!
○ Finger painting = HAND painting.
○ They do PARALLEL Play → play alongside, but not with
● Preschoolers:
○ Work on their FINE MOTOR → finger dexterity
○ Work on BALANCE → t ricycles, dance class, ice skates
○ Characterized by CO-OPERATIVE play →play together in groups
■ They like to PRETEND → highly imaginative!
● School Age:
○ Characterized by the 3 C’s:
■ Creative → blank paper & colored pencils
■ Collective → collect anything & everything
■ Competitive → they don’t like being the loser
○ Examples: legos, transformers, pokemon cards
● Adolescents:
○ Peer Group Association (hang out with their friends)
○ Question (pertaining to Nursing): Do you let 5-8 adolescents hang out in a room together?
YES!! You let them hang out UNLESS these 3 things:
■ If anyone is fresh post-op (less than 12 hours out of surgery)
■ If anyone is immunosuppressed
■ If anyone has a contagious disease
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Piaget’s Theory of Cognitive Development (4 stages for children’s thinking)
● Sensorimotor (0-2 y/o): totally present oriented; only think about what they are doing right now
○ Teaching Guidelines
■ When it is happening
■ What you are doing now
■ Tell them what you are doing as you are doing it
■ Pre-teach parents not the child
● Pre-operational (3-6 y/o): fantasy oriented, illogical, no rules
■ When: future tense; slightly ahead of time (“the morning/day of” or “two hours before”)
■ What: you will do
■ How: play, toys. stories
● Concrete operational (7-11 y/o): rule oriented, live and die by the rules, cannot abstract think
■ When: days ahead of time
■ What: you’re going to do and skills
■ How: age appropriate reading and A/V material; role play is OK
● Formal Operational (12+ y/o): able to think abstractly, understand cause/effect, think like adults
emotionally but physically not there but they can think like an adult. Can manage their own care
■ When: like an adult
■ What: like an adult
■ How: like an adult
■ Treat like an adult M/S patient
● FYI: What is the first age that a child can manage their own care? 12.
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HOW to take PSYCH Tests!! (7 principles)
● Make sure you know what phase of the relationship you are in
○ Pre-interaction Phase:
■ Purpose: for the nurse to explore his/her feelings and to prevent judgemental,
intolerant reactions
■ Length: it begins when you learn you are going to be caring for someone and it ends
when you meet them
■ Correct answer: “the nurse will explore their feelings about…”
○ Introductory Phase (Orientation):
■ Purpose: to establish and explore/assess
■ Length: it begins when you first meet the patient and it ends when a mutually
agreed-upon plan of care is in place
■ Correct answer: should be very tolerant, accepting, explorative, probing (nosy). Be
warm and fuzzy
○ Working Phase:
■ Purpose: to implement the plan of care
■ Length: from the finished care plan until discharge
■ Correct answer: should be focused, directive and “tough”. In some ways, the answers
will seem stern and slightly unfriendly. Set limits. Enforce proper communication.
○ Termination Phase:
■ It begins on admission
■ It begins when the problems are resolved, and it ends when the relationship is ended
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● Gift giving: Do not give/accept gifts from patients
● Don’t give advice- “What do you think you should do”
● Don’t guarantee anything- “If you talk to me I can help you/don’t cry you’ll feel better”
● Best answer is the one that keeps them talking (open ended),
○ It’s never wrong to get a patient to talk in any instance.
● Concreteness- Don’t use slang because psych patients take things literally.
○ Don’t ask them what their neologisms are
● *Empathy- acknowledge feeling, always be empathetic. Never choose answers like this “don’t feel...”
“don’t worry”, read the feeling in the question
○ BAD answers for empathy:
■ “don’t worry, don’t feel, you shouldn’t feel, I would feel, anybody would feel, most
people feel”... DON’T SAY THESE!!
○ 4 Step Process for Answering EMPATHY Questions:
■ Recognize that it’s an empathy question
● Always have a quote in the question & each answer is a quote
■ Put yourself in the pt’s shoes!
■ Ask yourself “if I said those words and really meant them; how would I be feeling?”
■ Choose the answer that reflects that feeling or anything close!
● Do NOT choose the answer that reflects their words!
● *Empathy ignores what is said and goes with what is felt*
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**11. Prioritization, Delegation & Staff Management
Prioritization > choose which pt is sickest or healthiest!
● If the question states, “There has been a trauma nearby and you have to discharge patients to make
room for the incoming traumas, who would you discharge?”
○ You are looking for the most stable patient (healthiest) to discharge.
● If the question asks, “You just got report on 4 patients, who do you see first?”
○ You are looking for the sickest patient
Priority/Delegation:
Determine which pt is the sickest or healthiest depending on the question:
● Age, gender, dx, and modifying phrase
○ Example: "10 yr old male w/ hypospadias who's throwing up bile & emesis."
■ Age and gender are irrelevant
■ Dx & modifying phrase is important, but modifying phrase is always more important.
■ Do not use ABCs
○ Example: A patient had angina pectoris vs a patient having an MI, which patient is the highest
priority?
■ The patient with the MI is higher priority
■ But, if the patient with angina has unstable BP with stable VS (modifying phrase) → now
the angina patient is higher priority because the MI patient has stable VS.
4 Rules for PRIORITIZATION:

● Acute beats Chronic
○ Example: You have the following patients: COPD (chronic), CHF (chronic) &
Appendicitis (acute: HIGHEST priority!)
■ If you used ABC’s, you’d choose COPD & you’d be wrong!
● Fresh post op (12 hours) beats medical or other surgical
○ Example: You have the following patients: COPD, CHF, acute appendicitis, 2 hour post
cholecystectomy (fresh post op: HIGHEST priority!), 2nd day post of coronary artery bypass
graft
● Unstable beats Stable (duh!) *talking right now; do NOT think otherwise!*
○ What makes a patient stable?
■ The word “stable”
■ Chronic illness makes you stable
■ Post op greater than 12 hours
■ Local or regional Anesthesia
■ Lab abnormalities of an A or B level
■ Phrases:
● “Ready for discharge”
● "To be discharged”
● "Admitted longer than 24hrs ago"
■ Unchanged assessment
■ Experiencing the typical expected signs and symptoms of the disease with which they
were diagnosed
○ What makes a patient unstable?
■ The word “unstable”
■ Acute illness
■ Post op less than 12 hours
■ General Anesthesia
■ Lab abnormalities of an C or D level
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■ Phrases:
● "Not ready for discharge”,
● "Newly admitted”
● "Newly diagnosed”
● "Admitted less than 24 hrs ago"
■ Changing/changed assessment (something new or different)
■ Experiencing unexpected signs and symptoms of the disease or complications with
which they were diagnosed
○ What 4 patients are always unstable, regardless if it is expected or not?
■ Hemorrhage (there is a difference b/w hemorrhage and bleeding)
■ Fever > 104oF (they could seize)
■ Hypoglycemia
■ Pulselessness or breathlessness
● **Unless it was unwitnessed, then they're dead already and not a priority**
○ Lowest priority: at the scene of an unwitnessed accident
○ Highest priority: at the scene of a witnessed accident
○ Example: 16/f with meningococcal meningitis, who has had a temp of 103.8oF since admission
3 days ago and 67/m with irritable bowel syndrome who spiked a temp of 100.3oF this
afternoon.
● Who is HIGHER priority?? **67/m because the temp (modifying phrase) is
*unexpected/newly changed*
16/f with meningococcal meningitis, who has had a 67/m with irritable bowel syndrome who spiked a
temp of 103.8oF since admission 3 days ago temp of 100.3oF this afternoon.
Diagnosis: Diagnosis:
● Meningococcal meningitis is high priority because ● IBS is low priority because it is chronic
it is acute Modifying Phrase:
Modifying Phrase: ● Spiked a temp of 100.3oF
● “Who has had…” → unchanged (low priority) ○ Is is expected? NO → unexpected →
● Temp of 103.8 → expected with meningitis (low high priority
priority) ● This afternoon → new/change → high priority
● Admission 3 days ago → low priority
3 things that result in Black Tags in an Unwitnessed Accident:

● Black tag = tag them black and ship them last
○ Pulselessness
○ Breathlessness
○ Fixed and dilated pupils (even if they’re still breathing)...low priority
Tie Breaker:
● CAUTION; only use as a tiebreaker!
● The more vital the organ, the higher the priority
○ The organ we're talking about is the organ of the modifying phrase is happening, not the dx
itself
Order of Organ Vitality:

● In order of most vital to least vital:
○ Brain ⇒ Lungs ⇒ Heart ⇒ Liver ⇒ Kidney ⇒ Pancreas
● Example:
○ 23/m with CHF (chronic, low priority) with potassium of 6.6 (C/D level > high
priority) & no EKG changes (low priority) → *heart*
○ Chronic renal failure pt (low priority) with a creatinine of 24.7 (low priority) & pink frothy
sputum (unstable, high priority) → *lung*
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○ **Patient with acute hepatitis (high priority) with jaundice (expected, low priority) & increased
ammonia level (expected, low priority) who you can’t arouse (unexpected, high priority)
→ *brain* (HIGHEST PRIORITY!!!)
Delegation
Delegation: LPN
● Do not delegate the following responsibilities to an LPN:
○ Starting an IV
○ Hanging/Mixing IV meds
○ Pushing IV Push meds
■ BUT they can maintain/document the flow
○ They can’t administer blood or mess with central lines
■ Including flushing or changing central line dressings unless that's the only option they
can do
○ They cannot plan the care
■ BUT they can implement but not create the care plan
○ They can’t perform/develop teaching
■ BUT they can reinforce the teaching
○ They can’t care for unstable patients
○ They can’t do the first of anything, RN must do the first of anything
○ They can’t do admission/discharge/transfer/first assessment after a change.
Example:
● Who should the LPN check?
○ Patient with angina pectoris with crushing substernal chest pain, admitted 3 days ago & is on
nitroglycerin
● Who should the RN check?
○ Patient who had a subtotal thyroidectomy 2 days ago & is asking, “why are they washing
elephants in the parking lot?” (thyroid storm... symptom = delirium)
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Delegation: UAP/Aid/Tech
● Do not delegate the following responsibilities to an UAP/Nurses Aid:
○ Charting → they can chart what they did BUT not about the pt
○ Giving meds EXCEPT for topical OTC barrier creams
○ Assessments other than vital signs and accu-checks (BS checks)
○ Treatments EXCEPT enemas... catheterize last resort
● You CAN delegate ADL’s but they should never do the first**
○ The RN should do them first.
Keep in mind: LPNs CAN do a lot of the things that *RNs are supposed to do* in an extended care facility,
because those pts are STABLE.
Do not delegate safety responsibilities to the family of the patient.

● I.E.: taking off restraints for a family member in the room)
● The RN is responsible for patient safety.
With sitters/caregivers, they can only do what you teach them to do and you must make sure you document
that you taught them.
Staff Management
● How do you handle inappropriate behavior amongst staff?
○ There are always four answers:
■ “Tell supervisor”
■ “Confront them and take over immediately”
■ “Approach them later on and talk to them about it”
■ “Ignore the behavior”
● Ignore the behavior is NEVER the answer.
○ You always take it an as opportunity to teach and change behavior
○ Ask yourself “Is what they are doing illegal?”
■ If YES → choose “Tell the supervisor” (always the answer in this case)
■ If NO → ask yourself “Is anyone in immediate danger of physical/psychological harm?”
■ If YES → choose “Confront immediately and take over” (always the answer in this case)
■ If NO and it’s just inappropriate, legal, and not harmful behavior → choose “Approach
them later on and talk to them about it” (always the answer in this case)
■ If it’s harmful and illegal → confront first then tell supervisor
Example: you are a LPN & suspect that a RN with whom you work is diverting narcotics for private sale and
use... is it ILLEGAL? YES. What do you do? tell supervisor!
Example: you are a LPN & you walk by the room of an UAP who is giving perineal care to a patient & the UAP
is NOT wearing gloves... is it ILLEGAL? NO. is anyone in danger by the behavior? yes, the UAP... what do
you do? confront them & take over immediately!
Example: you are a LPN & notice that a RN goes home every day with bulging pockets... is it ILLEGAL? YES
(could be stealing). what do you do? tell supervisor!
Example: you are a LPN in the OR & you notice the surgeon during surgery contaminates the pinky of his left
hand? is it ILLEGAL? NO. is anyone in danger by the behavior? yes, the pt... what do you do? confront them!
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Example: you are a LPN & when giving report a RN always says “exasperation” instead of “exacerbation”
when talking about a pt with COPD... is it ILLEGAL? NO. is anyone in danger by the behavior? NO... what do
you do? talk to them about it at a later date!
Example: you are a LPN & you see a RN take & swallow a pill... confront them & ask “what was that pill you
just swallowed?” *even if it’s a doctor!* NCLEX wants you to go after them!!! *SAFETY!!!*
Abdomen (HOT spot *point & click* for where ORGANS are!)
*You have some leeway on where you click, as long as you are in the general vicinity, you will get it right.
Heart (HOT spot *point & click* for valves of the heart!) A... PET... M!!
**Mitral > apical pulse
*You have to get it exactly on the spot to get credit.
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Pulses: carotid, brachial, radial, femoral
**HOW DO YOU GUESS with a question

Use knowledge first ⇒ then common sense ⇒ then educated guess
● Psych questions:
○ Best answer is “the nurse will examine their own feelings about...” to prevent
countertransference.
○ Another really good answer is “Establish a trusting relationship”.
● Nutrition questions:
○ In a tie, pick chicken (unless it’s fried), if chicken isn't there pick fish (not shellfish).
○ Also never pick casseroles for children.
○ Never mix meds in children’s food.
■ If you EVER mix meds in a person’s food; you must ask permission!
○ For toddlers choose finger foods.
○ Preschoolers leave them alone, one meal a day is okay.
● Pharmacology questions:
○ Memorize side effects of drugs.
○ If you know what a drug does but you don’t know the side effects, pick a side effect in the same
body system where the drug is working
■ Example: GI drug → pick diarrhea, HEART drug → pick tachycardia or a CNS drug→
pick drowsiness etc
○ If you don’t know what the drug is look to see if it’s PO pick a GI side effect (works about 50/50).
○ Never tell a child medicine is candy.
● OB questions:
○ Check fetal heart rate.
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● Med Surg questions:
○ The first thing you assess is LOC not airway
○ The first thing you do should be establish airway
○ When it doubt, call it abnormal
● Pediatric Growth and Development questions:
○ 3 Rules based on the principle:
■ Always give the child more time, don’t rush their growth and development
○ Rule 1: When in doubt → call it normal
○ Rule 2: When in doubt → pick the older age (out of the two answers you haven’t eliminated)
■ Example: At what age should a child begin to walk? 12 months or 14 months
● Correct answer is 14 months (giving them more time)
○ Rule 3: When in doubt → pick the easier task (out of the two answers you haven’t eliminated)
■ Example: What task should a 6 month child be able to do? Trying to roll over or sitting
up
● Correct answer is roll over (easier task)
● Rule out generalized absolutes if you’re guessing If two answers say the same thing, neither of them is
right.
○ If two answers are opposite, one of them is probably right
● The “umbrella strategy”: look for an answer that covers all the others without saying it does
○ Example: When you transfer a pt from the bed to a chair, what is important to do?
■ Bring the chair to the bed as close as possible
■ Remove the foot pedal
■ Use safety/good mechanics when transferring
■ Lead into bed with the strong food
● If the question gives you four right answers and the question is asking for prioritization, use the rules
above, however if they give you one patient in the question and it asks “which needs is highest priority”
don’t use it! Do the worst consequence game.
○ If the question give you 4 right answers & asks you to pick the need with the HIGHEST priority
■ Take each option (A, B, C & D) and ask “what is the worst thing that would
happen if I didn’t do this...”
■ Then choose the worst consequence!
○ Example: which of the following is the HIGHEST priority when caring for a suicidal pt?
■ If you don’t give him a tranquilizer...
■ If you don't orient them to the unit...
■ If you don’t put them on suicide precautions...
■ If you don’t introduce them to the staff...?
■ What’s the worst between being agitated, lost, dead or not knowing anyone?
➢ If you don’t put them on suicide precautions = dead!
○ Example: what’s the worst without sips of water... what’s the worst without pain meds...
what’s the worst if the side rails weren’t put up... what’s the worst without an abductor pillow
(??)
■ The answer to pick would side rails!! They could fall and break something
● When you’re stuck between two answers, re-read the question
○ The clue for the answer is in the question not the answer
● The Sesame Street Rule: (use as a last resort, when nothing else works)
○ Right answers tend to be different then the others because it is the only one which is right so
the other “wrong” answers have something in common
66
● Don’t be tempted to answer a question based on your ignorance instead of your knowledge.
○ Pull the “thing” you don’t know out of the question and answer it with the things you know.
○ Boards will give you things you never heard of to measure your common sense
○ Example: Which of the following is important to do in the administration of amikacin IV
piggyback?
○ Cover the bag with foil to protect it from light
○ Use an IV pump
■ Take the drug out of the question and answer what is important when
administering an IV piggyback
● If something really seems right, it probably is. DON’T go against your gut answer unless you can prove
why the other is superior
● Select all= It's never 1 and it's never all of them
○ 2017 change: it can be one answer or all of them
● Conflicts on the job: Never say “You”. Always say “I”
● Headache good thing to check on SATA!
● NEVER PICK INFECTION IN FIRST 72 HRS of anything!
3 Expectations CAN’T HAVE because they cause negativity:

● What FAILS people a lot... ☹ ..this breeds NEGATIVITY.. which then affects their performance
○ The test wasn’t what they expected
○ The test wasn’t what they were hoping for
○ The test wasn’t what they wanted
● Rule #1*: Don’t expect 75 questions,
○ Prepare to get all 265 questions. “I’m still in the game”.
● Rule #2: Don’t expect to know everything.
● Rule #3: Don’t expect everything to go right on test day
YOU HAVE PERSEVERANCE & STRENGTH OF

CHARACTER TO GET THROUGH THIS!!
67

Mark Klimek NCLEX Review

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1. Acid Base Principles

**Principle: acid base signs/symptoms..

pH UP ↑ K ↓ [ALKALOSIS] pH Down ↓ K ↑ [ACIDOSIS]

Tachycardia Tachypnea Bradycardia Bradypnea

*Causes of acid-base imbalance:

*Respiratory ​alkalosis ​⇒ OVERVENTILATION ventilator setting may be too ​high​.

Dependency/Codependency​ (​#2 problem​)

**NCLEX Tip: ​Always answer with the majority

Antabuse (disulfiram)/Revia​ ​-alcoholism medication *​aversion therapy!​*

Upper overdose LOOKS LIKE downer withdrawal

2 situations (highest priority):

Alcohol Withdrawal Syndrome vs. Delirium Tremens

AWS DT’s BOTH

Semi-private room Private room Anti-hypertensives

Regular diet NPO or Clear Liquids Tranquilizer

Up Ad Lib (no activity restrictions) Restricted bedrest (no bathroom B1 multi-vitamin

Do not restrain Should be restrained

ROUTE TROUGH (lowest) PEAK (highest)

IV 30 min before next dose 15-30 min after drug finished

IM 30 min before next dose 30-60 min after drug is given

SubQ 30 min before next dose See diabetes lecture

PO 30 min before next dose Forget about it

3. Cardiac and Meds

ACTION DEFINITION POSITIVE ↑ NEGATIVE ↓

Inotropic Strength of heartbeat Strong Weak

Chronotropic Rate of heartbeat Fast Slow

Dromotropic Conductivity Excitable Blocks/Slows conduction

What do Calcium Channel Blockers treat?​ (indications)

Calcium Channel Blocker side effects:

**Normal Sinus Rhythm

Premature Ventricular Complex

Anticholinergic Effects Cholinergic Effects

↓ Mucus Bronchodilation Bronchorrhea (large amounts of mucus in airway)

**Only clamp chest tube in an emergency

Water Seal Chest Tube Dry Seal Chest Tube

Rules for clamping a tube​:

CONGENITAL HEART DEFECTS

**4 defects of tetralogy of fallot:

-​How to teach how to use the different type of crutch GATES:

Narrowed self concept​:

Signs and Symptoms

**LISPRO (Humalog) 15-30 minutes 1-2 hours 3-6 hours

ASPART (Novolog) 15-30 minutes 1-2 hours 3-6 hours

**REGULAR (Type R) 1 Hour 2 hours 4 hours

**NPH (Type N) 6 hours 8-10 hours 12 hours

**GLARGINE (Lantus) Slow absorption; 1 No peak; no/low risk of 12-24 hours

DETEMIR (Levemir) 1-2 hours None 19-20 hours

● Exercise ​potentiates (decreases)​ insulin:

**​COMPLICATIONS​ (must know for NCLEX)

● High Blood Sugar in Type I DM- DKA Diabetic Coma [Hyperglycemia]

● Low Blood Sugar in Type II DM (Hypoglycemia)

● High Blood Sugar in Type II DM (Hyperglycemia)

● Long term complications are related to two problems:

6. Drug Toxic ​**KNOW**

DRUG THERAPEUTIC LEVEL TOXIC LEVEL

Lithium 0.6-1.2 >​ 2

Lanoxin 1-2 >​ 2

Aminophylline 10-20 >​ 20

Dilantin 10-20 >​ 20

*Respiratory alkalosis ⇒ OVERVENTILATION ventilator setting may be too high.

Dependency/Codependency (#2 problem)

**NCLEX Tip: Always answer with the majority

Antabuse (disulfiram)/Revia -alcoholism medication aversion therapy!

What do Calcium Channel Blockers treat? (indications)

Rules for clamping a tube:

-How to teach how to use the different type of crutch GATES:

Narrowed self concept:

● Exercise potentiates (decreases) insulin:

**COMPLICATIONS (must know for NCLEX)

6. Drug Toxic KNOW

Lithium 0.6-1.2 > 2

Lanoxin 1-2 > 2

Aminophylline 10-20 > 20

Dilantin 10-20 > 20

**Magnesiums do the OPPOSITE AS the prefix

The universal sign/symptom of electrolyte imbalance is muscle weakness (paresis)!!!

*ADRENAL CORTEX Diseases (diseases that start with A or C)

Position Hands below elbows Elbows below hands

Use an Alcohol-Based Solution:

BUN (blood urea nitrogen):

NMS MUST KNOW!!

-Probable/Presumptive “The Maybes”:

-Labor & Birth:

● Lie: Relationship between the spine of mom & spine of baby

● Presentation: Part of baby that enters the birth canal first

How to time contractions:

HIGH fetal heart rate (over 160) → OKAY

LOW baseline variability → BAD ☹

HIGH baseline variability → OKAY 🙂

LATE decelerations → BAD ☹

EARLY decelerations → OKAY 🙂

VARIABLE decelerations → VERY BAD ☹

The only antipsychotic pregnant women can get is Haldol