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Nursing Concepts with Mark Klimek Lectures 1 to 12

As a nursing student, your success depends on how well you understand and use key ideas. Mark Klimek’s set of talks is an important tool that can help you understand these ideas. Let’s explore how Mark Klimek’s lectures 1 to 12 can enhance your nursing education and empower you on your journey to becoming a competent and confident nurse.

Building a Solid Foundation

Mark Klimek lectures 1 to 12 provide a comprehensive and organized approach to nursing content review. Starting with lecture 1 and going through lecture 12, each lesson covers important topics that nursing students will learn about throughout their program. The goal of the talks is to make complicated ideas easy to understand and remember.

Key Takeaways from Mark Klimek’s Lectures

Simplification of Complex Topics: Mark Klimek has a special way of breaking down hard nursing ideas into pieces that are easy to understand. His classes stress how important it is to understand the basic ideas, which makes it easy to understand even the most complicated subjects.

Memory Tricks and Mnemonics: Mark Klimek’s use of memory aids, mnemonics, and catchy lines is one thing that makes his talks stand out. These memory tricks will help you remember things well so that you can do well on tests and in clinical practice.

Practice Questions and Rationales: To reinforce your understanding, Mark Klimek Yellow Book provides practice questions at the end of each lecture. These questions test your ability to think critically and give you a chance to use what you’ve learned. The thorough explanations explain why some answers are right and others are wrong, which helps you learn even more.

Mark Klimek Audio: Learn on the Go

Mark Klimek also has audio recordings of his meetings that you can buy. This tool lets you learn while you’re on the go, so you can take advantage of your commute or other times when you can’t sit down with a book. The Mark klimek audio format ensures that you can review the content whenever and wherever it is convenient for you.

Mark Klimek Yellow Book: A Comprehensive Resource

Alongside the lectures and audio recordings, Mark Klimek’s Yellow Book is another valuable resource. This book is a companion to the talks. It covers the same information in a clear and straightforward way. It gives you a summary of each lesson, the most important things to remember, and more practice questions to help you understand.

Empowering Your Nursing Education

By incorporating Mark Klimek’s lectures 1 to 12, Mark klimek audio recordings, and the Mark Klimek Yellow Book into your nursing education, you gain a powerful arsenal of resources to excel in your studies. These tools not only help you understand and remember important nursing ideas, but they also help you build critical thinking skills and boost your confidence.

In the end, Mark Klimek’s classes, audio recordings, and Yellow Book are a complete and effective way for nursing students to learn key ideas. These tools help students become great nurses by making things easier to remember, giving them practice questions, and putting them in an audio format. Take advantage of these tools and let Mark Klimek show you how to be a great nurse.

 

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Enhance Your Nursing Education with Mark Klimek Audio

When it comes to nursing school, it’s important to have access to good ways to study. One such resource that can significantly enhance your learning experience is the Mark Klimek audio series.

Flexible Learning at Your Fingertips

One of the best things about Mark Klimek audio is that it can be used in different ways. You can listen to the audio recordings anytime, anywhere, whether you are on your way to class, working out, or just taking a break. This lets you make the most of your study time and turn everyday moments into chances to learn.

Reinforcing Nursing Concepts

Mark Klimek’s audio series covers a wide range of nursing topics, providing a comprehensive review of essential concepts. By listening to these tapes, you can make sure you understand important nurse information and have a strong base to build on. The audio version lets you listen to the information over and over, which makes it easier to remember.

Memorable Mnemonics and Memory Tricks

The use of mnemonics and remembering tricks is one thing that makes Mark Klimek audio stand out. Mark Klimek has a knack for coming up with memorable lines and connections that make it easy to remember complicated information. These memory aids are helpful on tests and in clinical practice because they make it easy to remember important ideas.

Integration with Mark Klimek Lectures 1 to 12

Mark Klimek audio seamlessly integrates with Mark Klimek Lectures 1 to 12. By listening to the audio recordings at the same time as the talks, you can better understand what was taught in each class. The audio version adds another layer of reinforcement, which helps you understand the ideas from a different angle and improves your general understanding.

Supplemental Resource: Mark Klimek Yellow Book

To further enhance your nursing education, consider using Mark Klimek’s Yellow Book in conjunction with the audio series. The Yellow Book serves as a comprehensive guide, summarizing the content covered in the Mark Klimek Lectures 1 to 12 and audio recordings. It gives clear answers, key points, and more practice questions to help you remember what you’ve learned.

Success on Your Nursing Journey

Mark Klimek audio is an invaluable asset that can greatly contribute to your success as a nursing student. This resource gives you the tools you need to do well in your studies by making learning fluid, reinforcing nursing ideas, and using mnemonics to help you remember things. Combined with Mark Klimek lectures and the Mark Klimek Yellow Book, Mark Klimek audio forms a comprehensive toolkit that will guide you towards nursing excellence.

In summary, Mark Klimek audio is a strong tool for nursing students because it can be used in different ways, it reinforces nursing ideas, and it uses mnemonics to help students remember things. By integrating it with Mark Klimek Lectures 1 to 12 and utilizing the Mark Klimek Yellow Book as a supplemental resource, you create a robust learning experience that propels you towards success on your nursing journey.

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]]> https://1filedownload.com/2024-2025-nclex-exam-resources-mark-klimek-notes-and-books/feed/ 0 Mark Klimek Yellow Book Download Free https://1filedownload.com/mark-klimek-yellow-book-download-free/ https://1filedownload.com/mark-klimek-yellow-book-download-free/#respond Thu, 03 Aug 2023 22:53:44 +0000 https://1filedownload.com/?p=520652

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Unleashing Nursing Potential with Mark Klimek Yellow Book

To do well in school as a nursing student, you need to have access to high-quality study tools. One such resource that can significantly enhance your understanding of nursing concepts is the Mark Klimek Yellow Book.

Concise and Organized Content

The Mark Klimek Yellow Book gives information about nursing in a clear and concise way. Each section corresponds to the lectures and Mark Klimek audio recordings, making it easy to follow along and review the material covered. The book gives a thorough look at the most important ideas, making sure that you have a strong base in vital nursing knowledge.

Key Points and Summaries

Within the Mark Klimek Yellow Book, you will find key points and summaries for each lecture and topic. These short summaries compress the information into small pieces that are easy to digest. This makes it easy to quickly review and repeat important ideas. By looking back at these notes often, you can strengthen your understanding and remember more.

Additional Practice Questions

To test your knowledge and strengthen your critical thinking skills, the Mark Klimek Yellow Book includes practice questions. These questions are meant to make you think about situations you might face on tests or in clinical practice. By answering these questions and reading the explanations, you can improve your ability to think critically and feel more confident in your nursing knowledge.

Companion to Mark Klimek Lectures and Audio

The Mark Klimek Yellow Book serves as a valuable companion to the Mark Klimek lectures 1 to 12 and audio recordings. It helps you remember what you learned in each lesson and see how everything fits together. By utilizing the Yellow Book alongside the lectures and Mark Klimek audio, you create a comprehensive learning experience that enhances your understanding and retention of nursing concepts.

Empowering Nursing Students

The Mark Klimek Yellow Book is more than just a study guide—it is a powerful tool that empowers nursing students on their educational journey. By giving clear information, key points, and summaries, as well as more practice questions and smooth merging with the lessons and Mark Klimek audio, the Yellow Book equips students with the resources they need to succeed in their nursing education.

In summary, the Mark Klimek Yellow Book is something that nursing students can’t do without. Its information is organized and easily understood, and it includes key points and recaps as well as more practice questions. By utilizing the Yellow Book in conjunction with Mark Klimek lectures 1 to 12 and audio, you maximize your learning potential and pave the way for nursing success.

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]]> https://1filedownload.com/mark-klimek-yellow-book-download-free/feed/ 0 Mark Klimek’s Approach to Teaching and Learning https://1filedownload.com/mark-klimeks-approach-to-teaching-and-learning/ https://1filedownload.com/mark-klimeks-approach-to-teaching-and-learning/#respond Thu, 03 Aug 2023 22:46:41 +0000 https://1filedownload.com/?p=520646

Mark Klimek‘s approach to teaching and learning is based on a philosophy that emphasizes using real life examples to help students better understand the concepts that are taught in class. Using real-life examples to teach is one way to make a lesson stick with students and to ensure that they retain the information for years to come.

Mark Klimek’s Teaching Philosophy and Strategies

For over three decades, Mark Klimek has been teaching students in the School of Nursing. He has a strong belief in the importance of making sure that his students understand the information they are learning. He takes this concept even further by encouraging his students to participate in his courses and to ask questions.

Throughout his career, he has been able to use his unique perspective to help people learn about a variety of subjects. One of these topics is cardiac care. His experience with this subject ranges from cardiac intensive care to rehabilitation nursing.

Another one of his areas of expertise is health and culture. In this course, he helps his students to understand how different cultures affect people’s health. These factors play an important role in understanding how to improve the health of a person. If you’re interested in learning more about this topic, you can join one of his online tutoring sessions.

You’ll find that his sessions are held on Zoom. To get the most out of them, you’ll need a Zoom account and a valid email address. Each session will have a maximum of about forty attendees. Since there is limited seating, it’s important to sign up as early as possible. This will allow you to guarantee a seat.

Use Real-Life Examples in Mark Klimek’s Classes

One of the best ways to learn is to use real-life examples in your classes. For example, the Blue Book app is a great way to polish up your question-answering skills and the site also includes a 2500+ question database. Of course, if you’re looking for a more immersive experience, you can sign up for an online tutoring session with Mark Klimek, who’ll teach you how to answer the NCLEX style questions.

While there are plenty of options out there, I’d recommend using the one that’s the best fit for you. Using a free resource like the Blue Book app is a great way for you to see what other students are doing and get tips on how to do it yourself. In addition, you’ll be able to take your time with a smorgasbord of different question types.

Mark Klimek’s Tips for Effective Studying

If you are a student preparing for your NCLEX or are simply trying to hone your study skills, then you might want to consider a review by the legendary Mark Klimek. With more than 30 years of experience teaching nursing, he’s certainly not a beginner. He’s also got plenty of good advice for students of all ages and levels. In this article, we’ll take a look at the tips and tricks he’s been using to help his students master their studies.

One of the most important things to know about Mark Klimek’s reviews is that he doesn’t actually teach a course, but rather offers online tutoring sessions via Zoom. These sessions are free at first, but the number of attendees varies so it’s always wise to book a seat. To ensure that you won’t get left out, you’ll need to provide a valid email address, and you’ll need to have a Zoom account if you’re not already set up. You can sign up here, or contact him directly if you have any questions.

Other than that, he’s not exactly up to the task of offering a course that you can do anywhere. So, if you’re interested in his reviews, you’ll need to keep an eye out for the latest updates.

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The Mark Klimek Blue Book is the perfect resource for leaders of all levels. Written by Mark Klimek, a world-renowned business strategist and author, this book is packed with valuable insights and advice that every leader needs to know. From understanding the basics of leadership to developing strategies for success, The Mark Klimek Blue Book has everything you need to become a successful leader. If you’re looking to take your leadership skills to the next level, then you need to read The Mark Klimek Blue Book. With its wealth of information and insightful examples, this book will help you develop the skills you need to lead your team to success. Don’t wait any longer, order your copy today and start improving your leadership skills today!

Introduction

The Mark Klimek Blue Book is a compilation of insights, advice, and techniques from America’s foremost leadership expert and entrepreneur, Mark Klimek.

In this book, Klimek shares his unique insights and advice on topics such as:

  • How to build a successful business
  • How to lead a successful team
  • How to communicate with other leaders
  • How to drive innovation
  • And much more!

This book is a must-read for anyone who wants to take their leadership skills to the next level.

The Leader’s Role

The Leader’s Role is to provide a vision and set the tone for their team. They need to be able to motivate their team and set the example. They should also be able to think outside the box and be able to see the big picture.
As the Leader, it’s important that you stay calm under pressure and know when to give instructions and when to let your team do their thing. You also need to be able to handle criticism and know when to apologize.
It’s also important to be able to delegate tasks and be able to have a good relationship with your employees. You need to trust them and be able to give them feedback.

The Leader’s Character

If you want to be a great leader, you must have a great character. Unfortunately, this isn’t always easy to develop. There are a lot of things that can go wrong on the way to becoming a great leader.

One of the most important things you can do is have a clear vision for your company and for the people who work for you. This vision should be clear, concise, and inspiring. It should also be based on your company’s mission and values.

You also need to be able to handle difficult situations. Leaders need to be able to take criticism and handle conflict. They also need to be able to stay calm under pressure.

Last but not least, a great leader needs to be able to lead by example. If you want your team to follow you, you need to be a good leader yourself.

Leadership Styles

There are many different leadership styles, but the most common are autocratic, democratic, and participatory.

Autocratic leaders make all the decisions. They may be very good at delegating but they are the ones who make all the decisions.

Democratic leaders allow people to have a say in decisions but ultimately the final say rests with the leader.

Participatory leaders believe that everyone should have a say in decisions and that everyone should be able to contribute. This is the type of leader most people are used to.

There are also hybrid styles that combine some of the other leadership styles.

The most important thing is to find a leadership style that works best for your team and your organization.

Dealing with Conflict

Leadership is all about creating and leading teams to success. Conflict is inevitable, but how you handle it is critical to your success. In this book, Mark Klimek provides the keys to understanding and managing conflict in a way that leads to positive outcomes.
In today’s workplace, conflict is often seen as a negative thing. Leaders who can’t handle conflict can quickly lose credibility and be out of a job. However, effective conflict management is not about avoiding it; it’s about managing it so that it leads to positive outcomes.

In this book, you’ll learn:

  • The different types of conflict
  • How to identify and respond to conflict
  • The importance of communication
  • How to build trust
  • How to resolve conflicts in a positive way

This book is a must-read for leaders in any industry, and it will help you develop the skills you need to lead your team to success.

Handling Difficult People

As a leader, you will inevitably come across difficult people. This is a fact of life. However, you don’t have to go through it alone. The following tips will help you handle difficult people in a constructive way.
The first step is to understand that difficult people are just that, people. They are just like you and me with feelings, emotions, and perceptions.
Next, understand that they are not always right, and that they may not have all the facts.
Finally, remember that you are the leader, and you are the one who sets the tone and culture for your team. If you are able to remain calm, assertive, and respectful, then you will be able to handle difficult people in a constructive way.

The Team

Without a strong team, it’s difficult to achieve success. Leaders need to build and maintain strong teams in order to be successful. This involves understanding the different types of teams and how to best utilize them.
There are three types of teams: functional, autonomous, and collaborative.

Functional teams are the most common type and are made up of individuals who are assigned specific tasks and responsibilities. This type of team is useful for tasks that need to be completed in a specific order and are not too complex.
Autonomous teams are made up of individuals who are free to work on their own projects and are not limited by any specific tasks. This type of team is good for tasks that are complex and need creative input.
Collaborative teams are made up of individuals who work together to complete a task. This type of team is good for tasks that are complex and need cooperation.

Leaders need to understand the different types of teams and how to best utilize them in order to be successful.

The Organization

Leadership is a complex topic that requires an understanding of both the individual and the organization. In this book, Mark klimex breaks down leadership into eight essential concepts.

1. Vision. Leaders need to have a clear vision for the organization and for themselves. Without a vision, an organization will drift and eventually fail.

2. Values. Leaders need to establish and live by core values that guide their behavior. Without values, an organization will become unfocused and unprofessional.

3. Goals. Leaders need to set goals that are challenging but achievable. If goals are too easy to achieve, they become irrelevant.

4. Structure. Leaders need to create a structure that allows their team to function effectively. Without a structure, an organization will become chaotic and ineffective.

5. Communication. Leaders need to be effective communicators and be able to convey their vision, values, goals, and structure to their team.

6. Leadership. Leaders need to be able to lead their team and be accountable for their actions.

7. People Management. Leaders need to be able to manage people effectively, both in the short and long term.

8. Performance Management. Leaders need to be able to measure and track performance and provide feedback to employees in a consistent and effective manner.

The Future of Leadership

In the ever-changing world of business, it’s important for leaders to stay ahead of the curve. And what better way to do that than by reading The Mark Kilmek Blue Book?
This book provides readers with a comprehensive look at the future of leadership and how it will shape the business landscape in the years to come.

The book is divided into three parts: the first part provides a historical overview of leadership and its evolution; the second part focuses on the dynamics of leadership and how they’ve changed over time; and the third part looks at the future of leadership and how it will continue to evolve in the years to come.

The Mark Klimek Blue Book is an essential read for leaders in all industries, and I highly recommend it to anyone seeking to better understand the future of leadership.

Conclusion

In this book, I examined the seven principles of leadership and how they apply to every type of business. I hope that you have gained a better understanding of what leadership is and how it can help your business succeed.

Leadership isn’t a one-time event or a once-in-a-lifetime opportunity. It’s a continuous journey that you must undertake to stay ahead of the competition and ensure your business is successful.

I would love to hear your thoughts on the book and how it has helped you in your business. If you have any questions, please don’t hesitate to contact me. I would be happy to answer them.

Thank you for reading!

We hope you enjoyed our blog post about the Mark Klimek Blue Book. This book is a must-read for any leader in business. It provides you with the essential tools and strategies you need to be successful. We know that after reading this blog post, you will be armed with the knowledge you need to take your business to the next level. Thank you for reading, and we hope you take the time to share the post with your friends and followers!

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]]> https://1filedownload.com/mark-klimek-blue-book/feed/ 0 5 Reasons Why Mark Klimek is the Best NCLEX Review Instructor https://1filedownload.com/5-reasons-why-mark-klimek-is-the-best-nclex-review-instructor/ https://1filedownload.com/5-reasons-why-mark-klimek-is-the-best-nclex-review-instructor/#respond Thu, 03 Aug 2023 22:39:54 +0000 https://1filedownload.com/?p=520636

When you are looking for a review instructor to prepare you for your NCLEX exam, you need to find someone with a proven track record of success. That means someone who has spent years helping other students pass the test and is passionate about providing the most effective review program for you. One of the reasons that Mark Klimek is the best NCLEX review instructor for you is his commitment to personal attention and support. His teaching style is different from other instructors and he offers the latest and most comprehensive NCLEX review materials to help you study efficiently and effectively.

Klimek’s Unique Teaching Style

The Mark Klimek Nursing program is a thriving institution at Cedarville University. From its earliest days as a small cohort of thirty students, the program has risen to an enrollment of more than 500 students in the upcoming 2020-2021 school year. Despite its growth, the program maintains a student-centered philosophy that emphasizes the importance of hands-on learning.

To make this possible, Mark Klimek‘s program offers a variety of online and in-person review sessions. These include refreshers, which were initially free, as well as more expensive international sessions. Aside from the usual suspects, Klimek’s latest online offerings also feature a new NCLEX style question bank.

While Mark Klimek’s Nursing program may not be for everyone, it certainly offers a diverse and unique experience. For starters, the program is led by a man of many hats. Not only is he a professor, but he’s also a registered nurse. He’s been a nurse in a number of different settings including cardiac and surgical intensive care, neurological intensive care, and rehabilitation nursing. In addition, he’s been an instructor in Culture and Health, a required course that explores how health is shaped by culture and how it varies from one community to the next.

Comprehensive and Up-to-Date Review Materials

The NCLEX Review from Mark Klimek is a great resource for anyone preparing for the exam. He offers in-person review sessions and also new online tutoring sessions. You can find out more about his reviews by visiting his official website. For an additional fee, you can also receive a PDF version of his popular yellow book.

Another great resource is Justine Dawson. She is an expert in the NCLEX test and has a comprehensive nugget page. In addition to providing tips, she has also included pictures that can be viewed by both visual and non-visual learners. This makes the page easy to read and comprehend.

While I would not recommend using the Blue Book App, it is a useful tool for students who are looking to polish their question-answering skills. With 2500+ questions, it helps students improve their NCLEX-taking abilities. However, it can be a little confusing at first. To get started, you will need a Zoom account. Once you have a Zoom account, you can sign up for a review session. A small group of about 40 students will attend each review session. If you are a refresher, you will want to purchase a spot.

The next generation NCLEX will be available starting April 20, 2023. In addition to providing important information, it is a good idea to use the app to test your memorization. It also has some interesting features. Unlike traditional testing, this test uses computerized adaptive testing technology, which calculates the probability of each question being answered correctly. This technology allows the software to predict the next question it will give you.

Experience and Expertise in Nursing Education

Mark Klimek is a chemistry major who changed his path when his brother suggested that he pursue a career in nursing. His focus is in nursing education. He believes that learning is more than just taking notes. Instead, he encourages students to actively participate and engage with the material.

Klimek has experience in a variety of settings, including medical intensive care, rehabilitation nursing, and cardiac care. He has taught both at the undergraduate level and in the School of Nursing.

He also has an expertise in preparing candidates for the NCLEX test. He has taught courses in both BSN and AASN programs. Currently, he is a nursing professor at Cedarville University. In addition to teaching, he is also involved in continuing education for nurses.

As a nurse, he has served in a number of critical care roles, including cardiac, surgical, and neurological intensive care. He has been active in leadership positions, disaster/forensic work, and senior nursing student oversight.

As a nursing educator, he teaches Culture and Health and Transitional Clinical, preparing students for their senior year of study. The course allows students to explore the concept of health and illness through different cultures. The course is offered in-person and through Zoom. Initially, it was free, but it has since been ticketed. Students can also buy tickets to refresh sessions. This allows them to better plan their schedule and determine the number of attendees at each session.

Klimek has also helped countless students prepare for their certification exams. He is passionate about his job, and his knowledge and experience will be remembered for years to come.

His Proven Track Record of Success

If you’re looking for an NCLEX Review instructor, you might want to consider Mark Klimek. After all, he’s been teaching the nursing program since 1983. He began as a chemistry major, planning to study pharmacology. But his brother urged him to pursue nursing. That’s how he found his way to the nursing program.

In fact, he’s even got a track record of success as an NCLEX Review instructor. This man has worked in many different areas of the health care field, including cardiac, neurological, medical intensive care, and rehabilitation. During his years as a nurse, he has also served in leadership roles.

When he’s not teaching in the classroom, he’s developing new online tutoring sessions. Until recently, these sessions were free. However, he’s now charging a fee. These sessions involve small groups of about 40 people. They are held on Zoom.

To attend, you’ll need to create a Zoom account. You’ll also need to provide a valid email address. Once you have a spot, you’ll be able to schedule your sessions. The only drawback is that you’ll be required to reveal your answers.

Another review instructor you might want to look at is Pete Savard. His review is designed for international students. Besides providing important content for the NCLEX, he’ll also teach test-taking strategies.

Before deciding on a review course, you should do some research. There are a few places to look, including student testimonials and online reviews. A review course that doesn’t explain the material in an understandable manner can actually hinder your chances of passing the exam. Fortunately, there are plenty of options available.

His Personalized Attention and Support for Student

Mark Klimek‘s Personalized Attention and Support for Student and faculty is not your average textbook. In addition to offering a variety of online courses, the intrepid explorer will be treated to one-on-one tutoring sessions, a plethora of study aids, and a number of special event and faculty led seminars. The official website has an impressive library of scholarly material spanning the gamut from literature to historical research to a myriad of multimedia formats, including audio, video, and virtual classrooms. Moreover, the faculty is dedicated to helping students achieve academic and career success. From mentoring students and faculty to mentoring alumni, the faculty at Cedarville University is committed to providing a well-rounded education that is both academic and fun.

While the faculty is not currently accepting applicants for the aforementioned programs, the intrepid explorer can check out the official website to see if there are any openings in the near future.

Thank You;

https://www.ncsbn.org/

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]]> https://1filedownload.com/5-reasons-why-mark-klimek-is-the-best-nclex-review-instructor/feed/ 0 The best NCLEX practice questions https://1filedownload.com/the-best-nclex-practice-questions/ https://1filedownload.com/the-best-nclex-practice-questions/#respond Thu, 03 Aug 2023 22:36:51 +0000 https://1filedownload.com/?p=520633

The NCLEX, or National Council Licensure Examination for Nurses, is the qualifying exam for registered nurses in the United States. It is a challenging exam that test your knowledge of nursing practice. To help you prepare for the exam, we have compiled a list of the best NCLEX practice questions. These questions are based on the official NCLEX exam and will help you to test your knowledge of nursing terminology, concepts, and procedures. By practicing with these questions, you will be able to improve your skills and prepare for the NCLEX with ease. So whether you are preparing for the NCLEX or just want to improve your nursing knowledge, be sure to check out our list of the best NCLEX practice questions.

1. What is NCLEX?

The National Council for the Accreditation of Teacher Education (NCATE) is the nationally recognized authority on teacher education and professional development. NCLEX is the national licensure exam for nurses.

The NCLEX is a challenging exam that is used to determine whether a nurse is ready to be licensed and work in a hospital setting. The exam is given at the end of a nurse’s nurse education program.

There are five sections on the NCLEX. Each section is made up of multiple questions. The section is scored based on the number of questions that a nurse gets correct. Nurses who score well on the NCLEX are more likely to be successful in finding a job as a nurse.

The best NCLEX practice questions are ones that are similar to the real NCLEX. This is because the questions on the NCLEX are designed to test a nurse’s knowledge and skills.

2. What are the best NCLEX practice questions?

There are many great NCLEX practice questions out there, but which are the best? I’ve put together a list of the best NCLEX practice questions that will help you prepare for the NCLEX.

  • Which organ is most likely to fail in the body?
  • What is a major cause of sepsis?
  • What is the median lifespan in the US?
  • What is the average weight of a newborn in the US?
  • What is the average cost of a funeral?
  • What is the name for the virus that causes chickenpox?
  • How do you treat a person who has a fever that is not due to a conventional illness?

3. What are the types of questions?

There are three types of NCLEX questions: Nursing Process Questions, Patient Care Questions, and Clinical Skills Questions.

Nursing Process Questions ask you about the nursing process, such as how to give a physical examination, order lab work, and manage pain. Patient Care Questions ask you about patient care, such as how to handle a fever, give a medication, and respond to a emergency. Clinical Skills Questions ask you about specific clinical skills, such as how to calculate a pressure gradient, calculate a volume and pressure, and give a intravenous (IV) infusion.

Each type of question has its own set of tips that will help you get the most out of the question. For example, make sure you know the answer to questions about the nursing process before you even start the question. This will help you skip some questions and save time. And remember to always read all the questions before you answer them so you can be sure you’re providing the best care for your patients.

4. How do you find NCLEX questions?

There are many ways to find NCLEX questions. You can go to a website that offers NCLEX practice questions, you can go to a source that posts NCLEX-style questions on a daily or weekly basis, or you can look for NCLEX questions on social media.
When you find NCLEX questions, be sure to read the comments to get an idea of the difficulty level of the question. You can also use these questions to help you study for the NCLEX.

5. How do you prepare for NCLEX?

There are many ways to prepare for the NCLEX. You can purchase a prep book, take a course, or use a practice test. However, the best way to prepare is to use questions from the NCLEX-RN® simulation software.
The NCLEX-RN simulation software is a computer-based program that simulates the NCLEX-RN examination. This program includes questions from previous years’ exams, so you can practice with questions that are similar to the ones you will encounter on the real NCLEX-RN.
You can purchase a license to use the NCLEX-RN simulation software, or you can download a free trial version. The trial version allows you to use the software for a limited time. After you’ve used the trial version, you must purchase a license to continue using the software.

6. How do you answer NCLEX questions?

There are many ways to answer NCLEX questions and all of them have their pros and cons. You can read the questions and try to think of a specific answer, or you can use one of the many practice tests that are available online.

If you want to find the best NCLEX practice questions, the best place to start is by doing some research. You can find a lot of free NCLEX questions on the internet, but the best place to find high-quality questions is to purchase an NCLEX question bank.

There are two different types of question banks: flashcards and e-books. Flashcards are great if you want to take a quick quiz and review the information later, but e-books are better if you want to dig deep and learn everything there is to know about a specific topic.

If you’re not sure which type of NCLEX question bank is right for you, the best way to find out is by trying them out. You can find NCLEX question banks at most major bookstores, or you can purchase them online.

7. What are the categories of questions?

The NCLEX is a licensure exam for nurses and it is one of the most important exams that a nurse can take. The NCLEX is a computer-based exam and it has a lot of questions in different categories.

The NCLEX has five categories:

  • Science
  • Math
  • English
  • Social Science
  • Clinical Reasoning

There are a lot of questions in each category and it is important to study the questions in each category so that you can be prepared for the NCLEX.

Some of the questions in the Science category may involve questions about anatomy and physiology. Other questions in the Science category may involve questions about disease processes and treatments.

Some of the questions in the Math category may involve questions about algebra and geometry. Other questions in the Math category may involve questions about statistics and data analysis.

Some of the questions in the English category may involve questions about grammar and vocabulary. Other questions in the English category may involve questions about critical thinking skills.

Some of the questions in the Social Science category may involve questions about social studies. Other questions in the Social Science category may involve questions about human development.

Some of the questions in the Clinical Reasoning category may involve questions about patient care. Other questions in the Clinical Reasoning category may involve questions about pharmacology.

8. What are the worst NCLEX practice questions?

There are many NCLEX practice questions that are available on the internet. However, not all of these questions are the best for preparing for the NCLEX. In this article, we are going to discuss the five worst NCLEX practice questions.

  • Which law regulates nursing homes?
  • What is the difference between a fever and a heat stroke?
  • What is the difference between a respirator and an oxygen tank?
  • How do you determine the stage of labor?
  • What is the difference between a C-section and a vaginal delivery?

9. How to find the best NCLEX practice questions?

So you’ve decided to take the NCLEX? Congratulations! The best way to prepare is by finding the best NCLEX practice questions. There are plenty of websites that offer free or paid questions, but the best way to find the best questions is by finding a question bank that is specific to your area of study.
For example, if you’re studying for the NCLEXRN, you would want to look for a question bank that is specifically designed for RNs. There are many question banks that are designed for different areas of nursing, so make sure to find one that is tailored to your area of study.
Once you find a question bank, it’s important to study the questions. Don’t just take the first question that comes to mind. Make sure to thoroughly study the answer choices and how they relate to the question. This will help you to understand the concepts and build the knowledge that you need for the NCLEX.

10. How to answer NCLEX questions

There are a lot of NCLEX practice questions out there and it can be difficult to know which questions to answer and which to avoid.

The best way to answer NCLEX questions is to use a study plan. This will help you to understand the content and to know what topics to focus on.

There are also a lot of free resources available online which will help you to improve your skills.

There are a few things you should avoid when answering NCLEX questions. You should never guess, and you should never answer questions based on personal opinion.

We hope you enjoyed our blog post about the best NCLEX practice questions. NCLEX is a big exam and can be very intimidating, but with the right preparation, you can do well on it. We have compiled the best NCLEX practice questions on the internet for you to use as a study resource. We know that these questions will help you prepare for the real NCLEX exam, and we are confident that you will be able to pass it with flying colors! Thanks for reading, and we hope to see you on the inside!

Thank you ;

https://www.rn.ca.gov/applicants/lic-exam.shtml

https://sos.ga.gov/page/approved-programs-and-nclex-information

https://www.nyc.gov/site/sbs/about/pr20220408-nclexrn.page

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]]> https://1filedownload.com/the-best-nclex-practice-questions/feed/ 0 Mark Klimek’s Contribution to the Understanding of Pharmacology https://1filedownload.com/mark-klimeks-contribution-to-the-understanding-of-pharmacology/ https://1filedownload.com/mark-klimeks-contribution-to-the-understanding-of-pharmacology/#respond Thu, 03 Aug 2023 22:34:52 +0000 https://1filedownload.com/?p=520631

Mark Klimek is a medical doctor who has contributed a lot to the understanding of pharmacology. His work has helped many people around the world understand this important field of medicine. As a result of his research and writing, a lot of doctors have been able to improve their practice.

What is Pharmacology and Why is it Important?

Pharmacology is a branch of science that studies the chemical properties and the actions of drugs. This science uses basic concepts of biology and chemistry to understand how medicines affect living organisms. It aims to discover optimal solutions to disease prevention and treatment.

Pharmacologists may work in the laboratory or in a clinical setting. They also may be allied to regulatory bodies or government. In most cases, they start their career with an undergraduate degree in life sciences. Many then continue with a master’s or doctoral degree. The field is open to people with scientific minds, analytical minds, and people who enjoy making discoveries.

Pharmacology is an important subject, especially to those who have an interest in medicine and life science. The study of the effects of drugs on living organisms is a very useful way of understanding the physiology of cells and the failures of biological systems.

Pharmacology has become an essential part of health services. Its purpose is to provide information about the etiology of diseases and to investigate how medicines interact with cellular targets. By studying the adverse effects of drugs and the mechanisms by which they work, pharmacologists can make more effective pharmaceuticals.

While pharmacology is a highly interdisciplinary field, it is generally considered to be a branch of biomedical sciences. It incorporates knowledge from several different fields, including chemistry, physiology, molecular biology, and neuroscience.

Clinical pharmacology developed in response to the medical need to determine the risks and benefits of drug therapies. This scientific discipline has since evolved into a comprehensive study that includes the development of new drugs and the deliberate misuse of them.

Although pharmacology began as a separate discipline in the 19th century, its origins go back to the Middle Ages. It began as a compilation of medicines in pharmacopeias. Later, it was established as a distinct science by the establishment of the first university chair.

Early pharmacology focused on herbalism and plant extracts. For example, quinine was explained with its affinity for organs and tissues.

Drugs can be classified into crude, purified, or active ingredients. Crude drugs contain active ingredients, but they are not fully or properly purified.

Mark Klimek’s Research and Writing on Pharmacology

A long time Cedarville University nursing instructor, the granddaddy of all nurse educators, Mark Klimek is more than a steward to his students. For starters, he has been around for more than thirty years. As the school’s longest serving professor, he’s taught hundreds of aspiring nurses, some of whom are still in school today. In the last two decades, he’s compiled a wealth of knowledge, and a plethora of experiences in the nursing industry, from the helms of a small medical office to the head of a major hospital. His legacy is a solid one, and will be remembered for years to come. So if you’re looking for a high quality, low-cost, and fun nursing education experience, look no further. Besides, you’ll have the opportunity to rub shoulders with the big wigs, which can make for a fun and rewarding experience.

To date, he’s offered the aforementioned nursing program to well over 500 students in the upcoming 2020-2021 academic year. After which, he’ll be pouring his considerable skills into the ventures of his ilk. With that in mind, it’s only fitting that he’ll be hosting a series of online tutoring sessions in the near future. That is, if he’s still in the saddle when the dust settles.

The Impact of Mark Klimek’s Work on of Medicine

The baffling question of oh my god is this pharma geek a bit of a jack of all trades? Not to mention a half dozen gimmicks strewn about his office. As a result, the sultry grad has cult status among the faculty. One of the many perks is a plethora of shiny and shiny baubles to boot. Fortunately, for his mates and favs, he juggles the kinks with aplomb. Of course, it helps that he is the affable and the mantainment of his peers. In addition to his more than a dozen research based hares, he’s a devoted wife and a plethora of well awed kids.

Nclex Medicine Examination

Mark Klimek nclex is the Director of the School of Nursing at Cedarville University and has been teaching for more than 30 years. He began his career as a chemistry major who planned to study pharmacology. But at the suggestion of his brother, he switched to nursing. Today, he teaches Culture and Health, a class that allows students to investigate health in many different cultures. His students have the opportunity to work in many areas of the hospital, including cardiac, surgical, medical intensive, and rehabilitation nursing.

In addition to his teaching duties, Mark also prepares candidates for certification exams. He encourages his students to participate in discussions about the material, and believes that learning happens in a deeper way when students are engaged in the discussion. As a result, his courses have been popular with both undergraduate and graduate nursing students. This has helped the program to grow from a graduating class of thirty in the first year to over 500 students in the 2020-2021 school year.

Initially, his refresh sessions were offered free of charge, but that has changed. Now, they are limited to small batches of around forty students. That means you are guaranteed a seat, and can attend a refresh session if you are interested.

Sources;

https://www.etsy.com/market/mark_k_nclex

https://www.nclex.com/index.page

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Mark Klimek’s Top Tips for Acing the NCLEX Exam

If you are planning to take the NCLEX exam in the near future, you need to keep in mind that there are a few key things that you can do to make sure that you succeed. For instance, you will want to focus on mastering the various test-taking strategies that you can use to boost your score. You should also be prepared to stay focused and avoid distractions as much as possible.Here is a Mark Klimek’s Tips based advices.

Master the Test-Taking Strategies

The NCLEX test can be a daunting proposition. If you are not well prepared, you may be at a loss when the time comes to take the test. Fortunately, there are numerous resources available to help you pass this crucial exam.

First, you should be aware of the test format. This includes the number of items you can expect to see on the exam, the type of items, and the types of questions. There are also certain things you will not be allowed to bring into the testing room, including water and writing instruments.

Secondly, the NCLEX is a computerized adaptive exam. Your computer will adjust based on your performance to ensure you get the highest possible score. It is important to understand the types of questions and the strategies you should use to maximize your performance.

Third, you should practice taking the NCLEX. Several companies have developed review books that can provide you with the practice tests you need to prepare.

The Lippincott Guide to the NCLEX is a good start. It is a bestselling guide that features high-quality practice questions. Along with the standard book, you can purchase a companion online study guide that can help you learn about the test’s structure and take advantage of test-taking strategies.

Another great resource is the HESI Comprehensive Review. This test prep guide provides complete test information, hundreds of practice questions, and explanatory rationales. It is designed to align with the latest exam’s test plan.

Understand the NCLEX Test Plan

The NCLEX is a challenging exam, but there are ways to improve your chances of passing. Luckily, there are numerous resources that you can use to prepare for the test.

One of the best ways to improve your odds of success is to use a question bank. This is a resource that provides challenging questions in a format that teaches you how to think critically.

Another tool to consider is a review course. Several of these courses are available online. These courses are designed to teach students the most essential information they will need to pass the NCLEX. A review course will also improve your confidence level, so that you are ready to take the actual exam.

Some of the best review courses offer a combination of video, audio and online study tools. This enables you to get the most out of your study time. During the course, you will receive a personalized report highlighting the questions that you are most likely to fail, along with a set of study tips and tricks.

Other options include using the Blue Book App. This app contains over two thousand questions to help you practice your question-answering skills. While the Blue Book contains a variety of question formats, this app is unique in that it requires you to actually reveal your answers.

Lastly, I would recommend Mark Klimek’s NCLEX course. He explains the major topics of nursing in a streamlined way, which is a great way to learn.

Review the Key Nursing Concepts and Processes

If you are about to take the NCLEX exam, you need to know how to review the key nursing concepts and processes that will help you pass. The best way to do this is by practicing. You can find free practice questions online.

You can also purchase a study book for the NCLEX. These books will cover all the important topics and include a detailed answer guide. Taking time to study the material will improve your results.

One of the most important things to keep in mind when you are preparing for the NCLEX is to stay disciplined. This means not letting doubts or stress creep into your mind. It is also important to avoid cramming for the test.

The most common reason for failing the NCLEX is not enough time to prepare. For this reason, students should plan to complete their study plan at least a month before the date of the exam.

Students should also plan to take two online mock NCLEX exams. These tests will give them an idea of how long they can expect to spend on each section of the test.

Nursing school can be a challenging process. You may also have to deal with managing your time and home life. However, these things should be taken in stride.

One thing that you need to be aware of is that the NCLEX is a computer adaptive exam. In other words, it uses an algorithm to make sure that you are answering the questions correctly.

Practice with NCLEX-Style Questions

The NCLEX (Nursing Licensing Exam) is a challenging exam. It can be difficult to pass if you don’t have the right study tools or strategies. Luckily, there are many resources available to help you prepare.

The NCLEX is a computerized adaptive testing test. This means that the difficulty of the questions changes based on how well the tester performs. Basically, the harder the questions get, the higher your chances of passing.

One of the best NCLEX study tools is Justine’s Nugget Pages. These pages are organized, contain lots of tips and pictures for visual learners, and are full of minimum information necessary to pass the NCLEX.

Another study tool is the Brainscape flashcard. These cards are made in accordance with cognitive science principles. They are designed to enhance learning and boost your odds of getting the question right.

Another great NCLEX study tool is the Picmonic for Nursing. This book contains a ton of pictures and videos that help you learn the important nursing topics. You can also use this book on mobile devices.

Some other review resources include question banks. However, these should not be your sole source of study. To ensure you have a solid foundation, you need to use a variety of resources.

While these are some of the best NCLEX study tools available, you may need more help. For example, you might need help identifying your weak areas.

Manage Your Time and Pace Yourself

One of the best ways to prepare for the NCLEX is to enroll in a review course. These courses cover all of the important subjects and give you test-taking tips that will help you pass. You’ll also get a boost in confidence.

To find the most useful review, you’ll want to do some research. One way is to look for a course that has student testimonials. Another method is to check online reviews. This will ensure you’re getting the best deal possible.

The biggest tip is to remember that your score on the NCLEX is based on how well you answer a series of questions. As the number of questions increase, so do your chances of passing. For example, if you’re answering medium-difficulty questions correctly fifty percent of the time, you’ll bump up to a higher level.

One of the most useful study tools is the question bank. Question banks are designed to challenge your brain and get it to think critically. However, they shouldn’t be used for memorizing answers.

It’s a good idea to dress up like you’re taking the test. Even though you’re not, dressing as if you’re taking the test is a fun and unique way to kick start your preparation.

In addition, you’ll need a few other items to make sure you’re prepared. A notepad is a must. While you should not cram for the test, you should keep notes for each question.

Stay Focused and Avoid Distractions

If you are preparing for the NCLEX exam, you will need to learn how to stay focused and avoid distractions. You need to keep yourself from getting distracted by your surroundings, and also by electronic devices, such as cell phones, computers, and tablets.

While it may seem obvious, a distraction can ruin your NCLEX exam preparation. To combat distractions, you need to keep your study schedule organized. This way you know when you need to focus on studying, and when you need to move on to another topic. Also, don’t forget to eat a healthy breakfast before taking the test.

In addition to eating a healthy breakfast, you will want to make sure you have the right amount of rest and energy to take on the NCLEX. Your body will need eight hours of sleep to get you through the day. Make sure you set a regular bedtime so you can get up at a reasonable time the morning of the test.

Taking the time to prepare for the NCLEX will make you more confident when you sit down to take the actual exam. When you are feeling prepared, you will be more confident when you answer questions and will have a more positive attitude.

Make sure you know where the bathroom is, and that you are dressed comfortably. Practice deep breathing, and try to focus on something that will help you stay grounded.

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Mark Klimek’s Role in Advancing Patient Safety in Healthcare

If you are interested in patient safety, you might be interested in learning more about Mark Klimek and his role in advancing patient safety in healthcare. His research and recommendations have been used by hospitals around the country to help improve patient safety.

Mark Klimek’s Experience in Patient Safety

Mark Klimek’s experience in advancing patient safety in healthcare is something to be proud of. He has over 20 years of experience as a writer, editor, and educator, and his contributions have helped to enhance the quality of care that patients receive. He specializes in covering health related topics, from financial management to the best way to handle a patient emergency. The best part? He is an independent writer and not associated with any particular institution. As an independent author, Mark Klimek can speak from firsthand experience and bring a wealth of knowledge to the table.

To help improve patient safety, many healthcare institutions have adopted a number of measures, from regular staff education to feedback on specific fall incidents. These initiatives have a number of advantages, including improving the quality of care, lowering health care costs, and reducing the likelihood of a bad outcome. Of course, the best part is that the results are measurable, and the resulting data can be used for future comparative analysis. In fact, Mark has been so impressed with the data that he has decided to write a book on the topic. His goal is to provide an easy to read, information rich resource that anyone can use to improve their patient’s health and quality of life.

Mark Klimek’s Research on Patient Safety

The main objective of this study was to evaluate an alternative factorial structure of the patient safety culture model. A modification of the German Hospital Survey on Patient Safety Culture (HSPC) was used. This questionnaire was adapted to assess the views of health care professionals on patient safety in perioperative settings.

The survey was administered to all health care personnel at a hospital in Popayan, Colombia. It was tested for reliability and internal validity. Results were presented in a paper in Qual Saf Health Care.

The findings highlighted differences in perceptions between different professional groups and management levels. For example, physicians had higher scores, while administrative and nursing staff had lower scores. In addition, the study acknowledged organisational complexity and recognised the influence of clinical authority structures. However, the study suggests that further investigations are needed to understand how the four dimensions of the HSPC relate to the other factors.

The construct validity of the SF-36 questionnaire was investigated by calculating Pearson correlation coefficients between scale scores. Correlations were moderately high, suggesting that the factors were measuring the same concept. Additionally, the Cronbach alpha in the patient safety factors was in line with results from other countries.

In the same study, better teamwork was associated with improved patient safety. This result is in contrast to a Swiss study that found no correlation between teamwork and overall patient safety.

Mark Klimek’s Recommendations for Patient Safety

It’s no secret that healthcare is a growing industry, and it’s hard to make a dent in the number of healthcare related injuries and deaths each year. In order to stay one step ahead of the competition, organizations are experimenting with new innovations and trying to make better patient care a priority. Some examples include introducing electronic medical records and implementing mobile health technology in the form of wearable sensors, and improving the patient experience by increasing communication between health providers. A small but dedicated group of experts are analyzing these and other factors to develop a more holistic approach to patient safety. They hope to make their healthcare organization a safer place for patients, caregivers, and employees alike. The most important goal is to foster a healthy culture that will encourage staff to be a team player.

As part of their effort, they asked a panel of healthcare professionals to answer a series of questions about the most important medical and operational changes required to improve the health of patients. Their findings have been published in a paper in the Journal of Patient Safety.

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There are numerous ways that Mark Klimek‘s impact on the field of nursing education has been felt. His unique style of teaching is one of them. If you’re thinking about taking a nursing review course, you may want to look at his programs. They’ve proven to be very successful and will help you pass your exams.

Who is Mark Klimek?

If you are interested in studying for the NCLEX exam, then Mark Klimek is one of the best options to consider. He has been preparing candidates for the exam for more than 30 years, and has become known as an expert nurse. His teaching method is very effective, and he encourages students to actively engage with material.

During his career, he has worked in various settings outside the classroom, such as rehabilitation nursing, medical intensive care, and surgical intensive care. In addition, he has worked in leadership roles in both clinical and administrative positions.

Currently, he is a professor at Cedarville University. As such, he is very dedicated to the school. Since he has been teaching there, the school’s nursing program has grown to over 500 students in the 2020-2021 school year.

For more information about Mark Klimek, you can visit his official website. It is also possible to sign up for an online tutoring session. The sessions are held through Zoom, and you will need a valid email and Zoom account to attend.

Mark Klimek Background in Nursing

The impact of Mark Klimek on nursing education has been extensive. He is not only an expert in the field of Nursing, but has also played a key role in the evolution of the school of Nursing. Since he took on the job of teaching the School of Nursing at Cedarville University, his program has surpassed the number of students that it started with in its first graduating class. In fact, it has grown to over 500 students in the 2020-2021 school year.

One of the most important things that he does is prepare candidates for the NCLEX. This involves preparing them for the test, as well as giving them the knowledge they need to pass. He has been doing this for thirty years, and has helped more than a few people achieve their dreams of becoming a nurse.

Mark has not only been teaching the school of Nursing, but has also been active outside of the classroom. His work has taken him to the Dominican Republic, Thailand, and India, where he has worked to help the vulnerable population. Not only that, but he has also advocated for the rights of the homeless and indigenous people.

Success of Mark Klimek’s Nursing Review Courses

The success of Mark Klimek’s Nursing Review Courses in Nursing Education is not all that surprising. After all, the man has been teaching nursing students for over thirty years. He also has given numerous educational seminars, received a faculty of the year award and authored a number of curriculum reports for accrediting agencies. However, it’s his NCLEX reviews that have kept him in business.

A good review course should be able to show you how to prepare for the National Council Licensure Examination (NCLEX) and pass it the first time. The best part is you can take it again and again. You can also sign up for refresher sessions if you can’t make it to a live session. In fact, this type of review is a necessity for many nursing graduates.

Mark Klimek’s Nursing Review Courses are a worthy purchase for your hard-earned dollars. They might not be the most innovative way to hone your NCLEX skills, but they sure as heck are the most effective. Using the internet to your advantage, you can schedule an appointment for a session in the comfort of your own home. This is especially important when you are looking to score the best possible score on your NCLEX.

Unique Teaching Style

Mark Klimek is a professor of nursing who has been teaching since 1983. His style of teaching helps students prepare for the NCLEX. He believes that learning happens when students engage in the material. It is important to have an engaging teacher.

As a nurse, Klimek has worked in a variety of settings, including medical intensive care, cardiac and neurological intensive care, rehabilitation nursing, and surgical intensive care. Because of his experience, he is able to help his students succeed in their studies.

Mark Klimek has been a teacher for the School of Nursing at Cedarville University for many years. During his time there, he has helped the program expand from 30 students in its first graduating class to over 500 in its 2020-2021 school year.

Mark Klimek’s classes were initially free, but he has recently started offering refresher sessions. These sessions are limited, based on how many students are registered to attend. They are offered through Zoom, a video conferencing tool. In order to participate, you will need a valid email address and Zoom account.

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5 Reasons to Choose Mark Klimek’s NCLEX Review Course

If you are considering registering for an NCLEX review course, there are a few things to keep in mind when looking for the best option. These include the expertise of the instructor, the quality of the materials, and the availability of extra help and review. Taking advantage of the services of an experienced instructor is one of the most important things you can do for your NCLEX prep.

Comprehensive and Up-to-Date Review Materials

If you’re about to take the ol’ NCLEX exam, a well rounded review is a must. To get the best bang for your buck, you’ll want to pick something with an integrated syllabus, online tutoring and live practice tests. Luckily for you, there’s only one place to look for all of these: Mark Klimek. Unlike many NCLEX prep programs, Mark’s courses aren’t cookie cutter, ensuring you’ll get the right mix of high quality material and the highest level of instructor engagement. Moreover, you’ll only have to pay a fraction of the cost of a traditional tutoring session. Plus, you’ll be able to work in your own time.

Availability for Extra Help and Review

If you’re looking to pass the NCLEX, you’ll want to get your hands on the most efficient review course. This article will explore some of the best options available to you. Whether you’re considering a one-on-one or online review, you’ll find that there are several courses that stand out from the pack.

There are many review options, but you need to be mindful of some key factors. In particular, you want to check out the course’s pass rate. A low score on a test like the NCLEX indicates a review course that isn’t up to par. That is, you should look for a course that can give you the knowledge and confidence to pass the test.

Of course, there are also other NCLEX review options, such as courses offered by qualified agencies. However, these options aren’t always the best. It’s better to opt for a course with a proven track record, if you want to be sure that you’ll have the most efficient review. You can also contact a course provider to ask questions about the program. By doing so, you’ll know whether you need to stick with your current choice or look elsewhere. Alternatively, you can check out a one-on-one or online tutoring session with a respected professional. Some people believe that these sessions are more effective since you’ll be able to ask the instructor specific questions and you won’t have to worry about distractions.

Engaging and Interactive Review Sessions

If you’re looking for an engaging and interactive NCLEX review session, Mark Klimek’s School of Nursing offers online sessions via Zoom. In these sessions, a small group of about forty students are encouraged to engage with the material. However, there are some rules that you need to follow in order to participate. You will need a valid email and a Zoom account.

Mark Klimek has been teaching nursing students for over 30 years. His courses include Culture and Health, which enables students to investigate health through different cultures. This includes the physical, social, emotional, and spiritual aspects of wellness. He has also worked in a variety of environments outside the classroom, including rehabilitation and medical intensive care.

In addition to his NCLEX preparation course, Mark Klimek is also offering refresher sessions. Initially, these were free. Unfortunately, due to social distancing, these sessions have become limited. For these refresher sessions, you’ll need to buy a ticket, which will help determine how many people will be attending.

When choosing a review course for the NCLEX, you need to be sure that the content is well-organized and easy to understand. It’s important to find a course that’s relevant to the test’s latest NCSBN test plan. Also, you’ll want to read student testimonials. By doing so, you can make a more informed decision.

With the right review course, you’ll be able to feel more confident and prepare for the exam. However, you need to be aware of the fact that not all review courses are created equal. Read reviews and testimonials to find the one that’s right for you. The more information you have, the better prepared you’ll be for the exam.

Experience and Expertise in Nursing Education

When choosing an NCLEX review course, it is important to look for experience and expertise in nursing education. This helps students prepare better for the exam. Tutors who have recent clinical experience and knowledge can provide valuable advice.

The best NCLEX review courses will include a variety of resources. They should be able to explain the content in a way that is easily understood by students. In addition, they should be focused on current topics. There are hundreds of learning materials available on the web. If a course does not make its content accessible, it may compromise a student’s chances of passing the exam.

For instance, Justine’s nugget pages are a powerful resource for nursing students. These resources contain pictures for visual learners and tips for test-taking. She also has a section that contains the minimum information needed for the NCLEX.

Another good resource for studying for the NCLEX is Brainscape. This tool helps students learn the material faster. It generates questions in the same format as the real test. It also gives a personalized report of failed questions. Those answers can be reviewed for accuracy.

Mark Mueller has been providing state board (NCLEX) reviews for over 30 years. He is an expert nurse who explains difficult concepts in a creative and thorough manner.

While the official website of Mark Klimek states that the course is not recorded, it is not entirely true. During a refresh session, a small number of students are allowed to join. Since it is socially awkward for other people to attend, the sessions are limited. However, a refresher can guarantee a seat at the next session.

Unique Teaching Style

If you are preparing for the NCLEX exam, you are likely interested in the unique teaching style of the NCLEX review course from Mark Klimek. This program has been around for over two decades and has helped thousands of nursing hopefuls get their certifications on the right foot. The course is facilitated through a series of online tutoring sessions. These sessions are free of charge and can be accessed through a Zoom account. A valid email address and an account are required to attend. You can sign up for a refresher session or purchase a ticket for a full week of live instruction.

For a fraction of the cost of a private tutor, you can take advantage of the same type of hands-on practice that students have been using since the 1980s. Mark has a reputation for being a stickler for detail and will make sure that your test scores are on the right track. His school of nursing has grown from thirty to over 500 students in just two years.

Aside from the many sessions, Mark has made it easy for you to access his library of knowledge through a wide variety of online tools. For instance, a student can log on to a website, enter their test details, and have their test results delivered via email. Additionally, the site provides a slew of resources to help you prepare for the exam, including the NCLEX test simulator and the ol’ fashioned question and answer session. There is also an option for a one-on-one tutoring session where you can learn from the best.

Lastly, there are some cool perks to enrolling in this program, like a 20% discount on the picmonic high-yield practice question bank.

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Mark Klimek Short Questions and Answers

If the pH and the BiCarb are both in the same direction then it is?

Metabolic

 

If the pH is up it is?

Alkalosis

 

If the pH is down it is?

Acidosis

 

As the pH goes so goes my patient except for?

Potassium

 

If the pH is UP my patient will show signs and symptoms of…?

Increase… like tachycardia,diarrhea and borborygmi

 

If the pH is down my patient will show signs and symtoms of?

Decrease… like decreased output, bradycardia and constipation

 

If my pH is up my potassium (K+) is ?

Down

 

If my pH is down my potassium (K+) is?

Up

 

If my patient is overventilating I should choose?

Respiratory Alkalosis

 

If my patient is underventilating I should choose?

Respiratory Acidosis

 

If my patient has prolonged gastric vomiting or suction I choose?

Metabolic Alkalosis

 

If it is not lung or prolonged vomiting or suctioning I choose?

Metabolic Acidosis

 

High pressure alarms are triggered when?

They cannot push air in

 

High pressure alarms are caused by what three types of obstructions?

Kinking, Water in dependant loops and mucus in the airway.

 

If kinking in the tube is present you?

Unkink

 

If water is present in the dependant loops you?

Open system and empty water.

 

If mucus is present you?

Turn them, cough and have them deeo breath first. If ineffective you then suction.

 

Low pressure alarms are triggered when?

It is too easy to push air in.

 

Low pressure alarms are normally caused by?

Disconnection

 

If the tubing is disconnected you?

Reconnect

 

If O2 sensor line is disconnected you?

Reconnect

 

In a vented client respiratory alkalosis means the vent setting may be too?

High

 

In a vented client respiratory acidosis means the vent may be too?

Low

 

What do you do if the patients disconnected tube is on the floor?

Bag them, (call for help) get new tube and then reconnect.

 

What do you do if the patients disconnected tube is on the chest?

Reconnect … if its above the waist its ok.

 

What is the biggest problem in abuse?

Denial

applicable to all forms of abuse

To treat denial you need to?

Confront

 

How do you confront?

Point out the difference between what they say and what they do.

 

What is the one circumstance that you as a nurse would support denial?

Loss and Grief

 

What is dependency?

When the abuser gets a significant other to make decisions for them or do thing for them.

 

the abuser is dependent

What is codependency?

When the significant other gets positive self esteem from doing things or making decisions for an abuser.

 

To treat dependency/codependency you?

Set limits and enforce them. You also need to work or the self estreem of the codependent.

 

What is manipulation?

When the abuser gets the significant other fo do things for them that is not in the best interest of the significant other. This can be dangerous and harmful to the significant other.

 

How do you treat manipulation?

Set limits and enforce.

 

Why is manipulation easier to treat then dependency/codependency?

Because no one likes being manipulated.

 

What is Wernickes (Korsakoffs) Syndrome?

Psychosis induced by vitamin B1 (Thiamine) deficiency.

 

Vitamin B1 helps breakdown?

Alcohol

 

Primary symptom of Wernickes?

Amnesia with confabulation (making up stories).

 

Is Wernickes preventable?

Yes

 

Is Wernickes arrestable?

Yes

 

Is Wernickes reversible?

No

 

What is aversion therapy?

When you try and make the patient hate something.

 

Antabuse onset and duration is?

2 weeks

 

Teach a patient taking Antabuse to avoid what?

Alochol

 

On top of alcohol a patient taking Antabuse should also avoid what other 7 things?

Elixirs, Vanilla Extract, Aftershave/Perfumes, Alcohol based hand sanitizer, Insect repellant, Mouthwash and Vinagerette.

 

What are the five uppers?

Caffeine, Cocaine, Methamphetamines, PCP/LSD and ADHD Meds

 

Downers are?

Everything other then the five uppers.

 

S/S of upper use?

Everything goes up…Tachycardia, increased BP etc.

 

S/S of downer use?

Everything goes down…Bradycardia, decreased BP etc.

 

Overdose of a downer causes everything to go?

Down

 

Overdose of an upper causes everything to go?

Up

 

Withdrawal of an upper causes everything to go?

Down

 

Withdrawal of a downer causes everything to go?

Up

 

At birth if the mother was addicted to a substance always assume the newborn is in?

Intoxication

 

If 24 hours after birth assume the baby is in?

Withdrawal

 

Every alcoholic goes through what withing 24 hours after cessation?

Withdrawal syndrome

 

After 72 hours of alochol withdrawal a small minority may get?

Delirium Tremens

 

Can Delirium Tremens kill you?

Yes

 

Can Alcohol Withdrawal Syndrome kill you?

No

 

Are patients with Alcohol Withdrawal Syndrome a danger to themselves or others?

No

 

Are patients with Delirium Tremens a danger to themselves or others?

Yes

 

N/I for Delirium Tremens?

Private room near nurses station, NPO/Clear liquids, Restricted bed rest, restraints, tranquilizer, multivitamin (B1 vit.) and antihypertensive.

 

N/I for Alcohol Withdrawal Syndrome?

Semi-private room anywhere, regular diet, up and ad-lib, no restraint, tranquilizer, multivitamin (B1) and antihypertensive.

 

A two point restraint is?

One arm and the opposite leg.

 

N/I for restraints?

Check Q15min. and rotate sites Q2H

 

All aminoglycosides end in?

“mycin” Vancomycin

 

If it has “thro” in it you?

Throw it out…Zithromycin

 

Toxic effects of aminoglycosides?

Ototoxicity, nephrotoxicity and cranial nerve 8 (vestibulocochlear nerve) which senses sound.

 

In aminoglycoside use monitor?

Hearing, balance, tinnitus & creatinine (best indicator of renal function)

 

Frequency of administration for aminoglycosides?

Q8H

 

Aminoglycoside route of administration?

Im or IV

 

Aminoglycosides are given PO for what two reasons?

Hepatic Encephalopathy and Pre-op bowel surgery.

 

Neomycin and Kanmycin are used for what?

Bowel sterilzation?

 

Who can sterilize my bowel?

“Neo” “Kan”

 

Hepatic Encephalopathy is caused by?

High ammonia levels

 

What raises ammonia levels the most?

Ecoli in the gut

 

When do you draw a trough level?

30 minutes before the next scheduled dose.

 

When do you draw a sublingual peak level?

5-10 minutes after it is dissolved.

 

When do you draw a IV peak level?

15-30 minutes after dose is finished.

 

When do you draw a IM peak level?

30-60 minutes after given

 

Drugs DON’t determine peak and trough times, the ROUTE does.

…

 

Calcium Channel Blockers are like what for the heart?

Valium

 

Calcium Channel Blockers treat what? (the 6 A’s)

Antihypertensive, Anti-Anginal, Anti Atrial Arrythmia and SVTS

 

Calcium Channel Blocker side effects? (the 2 H’s)

Headache and Hypotension

 

What causes angina?

Chest pain due to O2 supply and demand issues.

 

90% of Calcium Channel Blockers end in?

“dipine” and “zem”

 

When giving a Calcium Channel Blocker you hold and notify if?

Systolic is 100 or lower.

 

“QRS” refers to?

Ventricular

 

“P” refers to?

Atrail

 

Asystole is?

A lack of QRS repolarizations

 

Atrail Flutter is?

Rapid P-wave repolarizations in a saw tooth pattern.

 

A-Fib is?

Chaotic QRS depolarizations

 

V-fib is?

Chaotic QRS depolarizations

 

V-tach is?

Wide bizarre QRS’s

 

PVC is?

Periodic wide, bizarre QRS’s

 

Be concerned about PVC’s if? ( the 6, 6 T’s of PVC’s)

More then 6 per minute, 6 in a row

 

What are the 2 lethal arrythmias?

A-systole and V-Fib

 

What are the 4 potentially life threatening arrythmias?

V-tach, A-fib, A-flutter and PVC

 

What are the 6 arrythmias you are tested over on the NCLEX?

V-fib, A-fib, A-flutter, PVC, A-systole and V-tach

 

What are the 6 arrythmias for NCLEX in order for prioritization?

A-systole, V-fib, V-tach, A-fib, A-flutter and PVC

 

When talking about arrythmias the word “chaotic” means?

Fibrillation

 

When talking about arrythmias the word ‘bizarre” means?

Tachy

 

PVC’s fall on what wave of the previous beat?

T wave

 

When given a prioritization question for lethal arrythmias if you are asked to prioritize and one say it happened 6 minutes ago and the other says 15 minutes ago which do you choose?

Always the one closest to the 8 minute mark. After 8 minutes the survival rate is LOW.

 

To treat PVC’s you give?

Lidocaine/Amnioderone

 

To treat V-tach you give? (If it start with a V you use..)

Lidocaine/Amnioderone

 

To treat supraventricular arrythmias you give?

Adenocard, Beta-blocker (end in “lol’), Calcium Channel Blocker and Digitalis or Lonoxin.

 

Supra means?

Above

 

To treat V-fib you ?

Defibrillate … For V-fib you D-fib

 

To treat AsystolE you give?

Atropine and Epinephrine but give it in reverse.

 

If asked how to treat A-fib first you?

Give Heparin then ABCD…. Heparin is instant Coumadin and Plavix take time.

 

An Apical chest tube is placed?

High (for air) A for air

 

A Basilar chest tube is placed?

Low (for blood) B for blood

 

If you are asked about chest tubes after a surgery or trauma you can assumes it’s a?

Unilateral Pneumohemothorax

 

Does a pneumonectomy get a chest tube?

No

 

What 4 things do you do if the water seal breaks on a chest tube?

Clamp it 1st!! Cut broken device off of tube, put the tube in water (NS), unclamp.

 

If asked about the best thing to di if the water seal breaks and not asking the first thing to do you?

Put it in water (NS).

 

What 4 things do you do if a chest tube comes out?

Cover hole with a gloved hand, put on a vaseline gauze dressing, put on sterile dressing ands then tape on 3 sides.

 

How long can you clamp a chest tube?

No longer then 15 seconds without a doctors order.

 

What do you use to clamp a chest tube and why?

Rubber tipped double clamps. Rubber because it won’t pierce the tube and double because were nurses and if one is good two is better.

 

Is bubbling in the water seal continuously good?

No it is bad. You need to find the air leak, tape it, report it and then record it.

 

Is bubbling in the water seal intermittently good?

Yes it should tidal on inhale.

 

Is bubbling in the suction control chamber intermittently good?

No it is bad. You need to dial up the suction, report and record.

 

Is bubbling in the suction control chanber continuously good?

Yes

 

All congenital heart defects that are trouble start with a ?

“T”

 

What defects have right to left shunts and are cyanotic?

Trouble defects

 

What defects have left to right shunts and are acyanotic?

Not trouble defects

 

All congenital heart defects have what?

Murmurs and Echocardiogram

 

What are the four defects of Tetrology of Fellot?

Ventricular Defect, Pulmonic Stenosis, Overriding Aorta and Right Hypertrophy

 

What is the saying to help remember the four defects of Tetrology of Fellot?

VarieD PictureS Of A RancH

 

1 fingerwidth is how many cm’s?

1

 

When the handgrip of a crutch is properly in place the elbow felxion should be?

30*

 

Crutches should be how many fingerwidths below the armpit?

2-3

 

Describe a 2 point gait?

one crutch and opposite foot together 2. Other crutch and other foor together.
2 points 2gether and the same time.

 

Describe a 3 point gait?

Move two crutches and bad leg together. 2. Move good foot.
Move all three together and then the good leg.

 

Describe a 4 point gait?

One crutch 2. Opposite foot. 3. Other crutch. 4. Other foot.
It moves one at a time so 1,2,3,4 and 1,2,3,4, and 1,2,3,4 so crutch, foot, other crutch, other foot, and crutch,foot, other foot, other crutch etc,

 

Describe swing through?

Used for two braced extremeties 1. Crutches 2. Legs… they kind of hop.

 

Use the even numbered gaits when weakness is?

Evenly distributed (bilateral)

 

When using the even gaits what one is for severe and what one for mild problems?

2 point gait for mild 4 point gait for severe.

 

Use the odd numbered gait when?

The problem is affecting one leg (unilateral)

 

Going up the stairs or down the stairs with crutches patient must remember…

UP with the GOOD and DOWN with the BAD

 

Crutches always move with what leg?

The bad leg.

 

What side do you hold the cane?

Strong side.

 

What side do you advance the cane with?

The weak side for a wide base support.
Step with opposites

 

For walkers remember you?

Pick it up, set it down and walk to it.

 

What is a delusion?

A false fixed belief, idea or thought.
This has no sensory component.

 

What are the three types of delusions?

Paranoid or Persecutory, Grandiose and Somatic

 

What is a paranoid delusion?

False fixed belief that people are out to harm you (CIA, FBI).

 

What is a grandiose delusion?

False fixed belief that you are superior (God, the Pope).

 

What is a somatic delusion?

False fixed belief about a body part (X-ray vision).

 

What is a hallucination?

False, fixed sensory experience.

 

Five types of hallucinations?

Auditory, visual, tactile, olfactory and gustatory.

 

What is an illusion?

Misinterpretation of reality.
It is a sensory experience.

 

How can you diffirentiate between illusions and hallucinations?

There is a referent ( something to which they refer). So the patient takes something from reality and has a sensory response.

 

What are the four types of functional psychosis?

Schizophrenia, Schizoaffective disorder, Major depression/mania (bipolar).

 

If a functional psychotic is having a delusion or illusion you?

Acknowledge the feeling ( that sound horrible), present reality (but we have no spiders in the room), set a limit ( were not going to talk about that lets talk about something else), enforce the limit ( I see you’re to ill to talk about reality).

 

5 examples of psychosis of dementia?

Alzheimers, dementia, organic brain syndrome, wernickesand seniality.

 

What do you do if a patient with psychosis of dementia is having a hallucination or illusion?

Acknowledge and Redirect.

 

What is flight of ideas?

Jump from word to word. (This room is big, I liked the movie BIG when they were on the piano, Elvis could play the piano).

 

What is word salad?

Jump from word to word. Bob, Car, Sleep, Foot etc..

 

What is neologisms?

Make up new words.

 

What is a narrowed self concept?

When they refuse to leave the room or get dressed. (DON’T force them to do it)

 

What is ideas of reference?

When they think everything is about them. (Everyone is talking about me)

 

Type I Diabetes (IJK)?

Insulin dependent
Juvenile onset
Ketosis prone (makes ketones)

 

Type II diabetes? (non all of the above)

Non insulin dependant
Adult onset
Non ketosis prone

 

Diabetes S/S?

Polyuria, Polydypsia and polyphagia (hunger)

 

How do you treat type I diabetes? (DIE)

Diet 3
Insulin 1
Exercise 2

 

How do you treat type II diabetes? (DOA)

Diet 1
Oral hypoglycemic 3
Activity 2

 

Type II diabetics need how many calories a day?

1,200-1,800

 

Type II diabetics need how many feedings a day?

6

 

What two drugs can increase blood sugar?

Glucagon and Epinephrine

 

If client exercises more they need?

Less insulin

 

If client exercises less they need?

More insulin

 

When a client is sick what does it do to there blood sugar?

It increases it.

 

Teach diabetics who are sick to?

Take insulin, take sips of water to stay hydrated and stay as active as possible.

 

What are the 4 types of insulin?

Regular, NPH, Humalog and Lantus

 

Regualr insulins all have what in them?

R

 

Regular insulin onset?

1 hour

 

Regular insulin peak

2 hours

 

Regular insulin duration?

4 hours

 

NPH insulin all have a what in them?

N

 

NPH onset?

6 hours

 

NPH peak?

8-10 hours

 

NPH duration?

12 hours

 

NPH is not so fast and not in the bag (IV)

…

 

Regualr insulin is rapid and run

…

 

With humalog when do you give it?

With meals

 

Humalog onset?

15 minutes

 

Humalog peak?

30 minutes

 

Humalog duration?

3 hours

 

What is the only insulin safe to give at bedtime?

Lantus/Glargine

 

Which insulin works the fastest?

Humalog

 

What are the three reasons that cause low blood sugar in type I diabetes?

not enough food, to much insulin (#1) and too much exercise.

 

What is the biggest danger with low blood sugar?

Brain damage if its less then 15

 

S/S of low blood sugar are?

The same S/S of shock and being drunk… clammy, weak, slurred speach etc.

 

Treatment for low blood sugar in type I diabetes?

Rapidly metabolizable carb or ideally a carb/protein combo or carb/starch combo.

Unconscious (NPO): give glucagon IM or dextrose IV.

 

Examples of rapidly metabolizing carbs?

Juice, hard candy, icing, honey, syrup

 

Diabetic Ketoacidosis (AKA high blood sugar in Type I diabetes) is caused by what 3 things?

Too much food
Not emough insulin
Not enough exercise

 

What is the #1 cause of DKA?

Viral upper respiratory infection within last 2 weeks.

 

DKA S/S?

D-ehydration
K-etones in the urine and blood, Kussmaul Resp and K+
A-cidosis, Acetone breath, Anorexia d/t nausea

 

DKA treatment?

IV at high flow rate (200hr.) with insulin R (it doesnt matter what solution its in)

 

Treatment for low blood sugar in Type II is the same as Type I low blood sugar treatment.

…

 

High blood sugar in type II diabetes aka hyperosmolar, hyperglycemic, non-ketotic coma (HHNK) is the same as?

Dehydration

 

HHNK S/S?

Same as dehydration

 

Treatment for HHNK is?

Rehydrate but no insulin in the bag because it is not type I diabetes. You only give insulin in the bag with type I diabetes because they burn fat and it turns to ketones.

 

What are the two long term problems from diabetes?

Peripheral neuropathy and poor tissue perfusion.

 

What lab is the best indicator for long term blood sugar maintenance?

HGBA1C aka glycosated hemoglobin

 

Lithium therapeutic level?

0.6-1.2

 

Lithium toxic level?

over 2.0

 

Lanoxin (digoxin) therapeutic level?

1-2

 

Lanoxin (digoxin) toxic level?

Over 2.0

 

Aminophylline therapeutic level?

10-20

 

Aminophylline toxic lever?

Over 20

 

Dilantin therapeutic level?

10-20

 

Dilantin (Phenytoin) toxic level?

Over 20

 

Elevated bilirubin level?

10-20 neonate only

 

Toxic bilirubin level?

Over 20 neonate only

 

Dilantin is an?

Anticonvulsant

 

Aminophylline is an?

Airway antispasm

 

Lanoxin(digoxin) is for?

CHF, Atrial arrhythmia

 

Lithium decreases?

Mania

 

What is Kernicterus?

When bilirubin is over 20 and in the CSF(cerebrospinalfluid)

 

What is Opisthotonos?

Position of hyperextension seen with kernicterus. Place them on there side if present.

 

If kernicterus and opisthotonos are occuring you?

Call doctor, drae bilirubin level, increase the IV rate and start billi lights.

 

Hiatal hernia is?

Gastric contents moving in the WRONG DIRECTION and the CORRECT RATE.

 

Dumping syndrome is?

Gastric contents moving in the RIGHT DIRECTION and the INCORRECT RATE.

 

S/S of hiatal hernia are?

GERD upon lying after meals

 

S/S of dumping syndrome are?

Acute abdominal distress= gas, ^bs, cramping, bloat
Dumping= s/s of being drunk
Syndrome= s/s shock

 

3 treatments for hiatal hernia is?

High fowlers during and 1hr after meals
Increase fluids with meals
Increased carbs

 

3 treatments for dumping syndrome?

Lay flat on side during and 1hr after meals
Decrease fluids during meals(drink between meals)
Decrease carbs (aka ^ protein diet)

 

Kalemias do the same as the prefix except for the what?

The HR and urine output.

 

Calcemias do the opposite of the prefix plus all what?

BP changes

 

What is Chvosteks sign?

Push the cheek and it spasms

 

What is Trousseaus sign?

BP cuff inflated and causes a carpal spasm.

 

Magnesemias do the opposite of the prefix plus all what?

BP changes

 

If in a tie never pick magnesium. If the symptom involves nerve or skeletal pick calcemia. For any other symptom pick potassium.

…

 

What is the rule for Natremias?

The one with the E id dehydration the one with the O is overload
HypErnatremia has s/s of dehydration and HypOnatremia has s/s of fluid overload.

 

Earliest sign of an electrolyte overload is?

Numbness and tingling (parasthesia)

 

Universal s/s of an electrolyte imbalance is?

Muscle weakness (AKA paresis)

 

Nere push what electrolyte?

K+

 

To decrease K+ you give?

D5W with Insulin R (insulin pulls the K+ from the blood and pulls it in the cell with glucose. this buys time but doesnt solve the problem)

 

Kayexelate does what?

Gets rid of K+ slow and late
K-exits-late

 

How much K+ can you have per liter of IV fluid?

40 mEq

 

What two words mean the same thing as immunosuppresion?

Agranulocytosis and neutropenia.

 

Hyperthyroidism (AKA graves disease) is the same as saying?

Hypermetabolism

 

S/S of Hyperthyroidism?

Same as hypermetabolism… agitated, nervous, diarrhea, hot, ^HR, ^BP, thin, hyperactive etc.

 

Remember RUN yourself in the GRAVE

Hyperthyroidism (Graves Disease)

 

Graves disease treatment options are? (3)

1.Radiation with I131 (radioactive iodine) 1st 24hrs be alone and flush the toilet alot. 2. PTU(drug) worry about immunosuppresion. 3. Surgical removal.

 

What are the two types of Thyroidectomys?

Total and Sub-total.

 

With a Total Thyroidectomy what do they need for life?

Hormone replacement (Synthroid)

 

What are you at risk for following a Total Thyroidectomy?

Hypocalcemia (parathyroid regulates calcium)

 

For a Sub-total Thyroidectomy you are at risk for what?

Thyroid storm

 

S/S of a Thyroid storm are?

The same as Graves Disease but incredibly higher.

Exp: HR 180, Temp 108*, psychotic delirium.

 

Thyroid storm treatment?

High flow O2, 5 ice packs= 2 under each arm, 2 groin, 1 back of neck.

 

Post Op Thyroidectomy risks 1st 12 hrs?

Hemorrhage and airway. After 1st 12hrs assume they are stable.

 

Post Op thyroidectomy risks 12-48 hrs for Total Thyroidectomy?

Tetany

 

Post Op Sub-Total Thyroidectomy risks 12-48 hrs…

Thyroid storm

 

Hypothyroidism is the same as saying?

Hypometabolism

 

Hypothyroidism S/S?

Same as hypometabolism ie, tired, sluggish etc

 

What is the name of the disease for hypothyroidism?

Myexedema

 

Treatment for hypothyroidism?

Hormone supplement

 

If asked a question and your patient is critical remember to always STAY with the patient!!

…

 

Do you sedate a patient with hypothyroidism (myxedema)?

No, you could put them into a coma. This patient is already low in consciousness.

 

If a patient with hypothyroidism is NPO for surgery you still give them what?

Hormone replacement medication.

 

What is Addison’s Disease?

Under secretion of the adrenal cortex.

 

S/S of Addison’s Disease?

Hyperpigmentation and do not adapt well to stress.

 

Addisons Disease treatment?

Chronic steroids (glucocorticoids)

 

With Addison’s Disease you ADD what?

ADD-A-SONE

 

Cushing Syndrome is the oversecretion of?

The adrenal cortex.

 

S/S of Cushing’s Syndrome?

Think of the Cush Man… Moon face, buffalo hump, thin legs and bones, striae (stretch marks), male breasts, hirstusism etc,

 

Cushings Syndrome treatment?

Adrenalectomy

 

Contact precautions are used for what 4 types of diseases?

RSV, Herpatic infection, Staph infections and Enteric (bowel) infections

 

Contact precautions have what 5 things?

Private room – door can be open
Gown- if giving direct care
Gloves
Handwashing
Disposable supplies

 

Droplet precautions are for what 2 diseases?

All meningitis and all influenza

 

Droplet precations have what 6 things?

Private room- door can be open
Gloves
Mask- #1 in this group
Handwashing
Pt wears mask when leaving room
Disposable/dedicated equipment

 

Airborne precautions are for what 4 diseases?

SARS, TB, Measles and Varicella

 

Airborne precautions have what 9 things?

Private room-door closed
Mask
Gloves
Gown
Handwashing
Special filter respirator masks
Pt wears a mask when leaving room
Disposable/dedicated supplies
Negative airflow room

 

PPE contains?

Gloves, gown, gogles and mask unless told otherwise.

 

Proper order for donning PPE?

  1. gown
    2. mask
    3. goggles
    4. gloves

 

Where do you remove PPE?

In the room.

 

Where do you put on PPE?

Outside the room.

 

Proper order for removing PPE?

  1. gloves
    2. goggles
    3. gown
    4. mask

 

In airborne precautions it is ok to remove what piece of PPE outside of the room?

Mask

 

What position are your hands for handwashing?

Hands below elbow

 

How long do you wash for handwashing?

15 seconds

 

Can the faucet have handles for handwashing?

Yes

 

What do you use in handwashing?

Soap and water

 

When do you wash your hands?

Before and after gloves
Entering and exiting a room
After you soil your hands

 

What position are your hands in for scrubbing?

Elbows below hands.

 

What is the length for hand scrubbing?

3-7 minutes

 

What do you use for hand scrubbing?

Cleaning agent must have the prefix “chlor”

 

Can the sink have handles for scrubbing?

No

 

When do you use scrubbing?

Immunosuppresion, surgery, transplant, chemo, HIV

 

Dry yours hands from…?

Cleanest to least clean

 

You can use alcohol based solution when?

Before and after gloves, entering and leaving a room

 

What can children under for not have?

Small toys

 

If a child has O2 is use what type of toys can’t be used?

Metal

 

What is the best toy for a 0-6 month old?

Musical mobile (get rid of this at 6 months or when the child is sitting up)

 

What three things should you ask yourself when choosing appropriate toys for kids?

Is it safe
Is it appropriate
Is it feasible

 

What is the 2nd best toy for a 0-6 month old?

Anything soft and large

 

What is the best toy for a 6-9 month old?

Cover/uncover toy

 

What is the second best toy for a 6-9 month old?

Anything large that they can’t swallow.

 

What is the best toy for a 9-12 month old?

Talking toy.

 

What is the second best toy for a 9-12 month old?

Anything that is purposeful (rolling a ball back and forth)

 

What 5 words should you avoid when answering a question about toys for a child under 9 months old?

Build
Make
Construct
Sort
Stack

 

What is the best toy for a toddler (1-3 yr.)?

Push/pull toy

 

What should you work on with a toddler (1-3 yr.) ?

Gross motor

 

What is toddler (1-3 yr.) play characterized by?

Parallel play (with another child but alone)

 

What two things should you work on with a preschooler (3-6 yr.) ?

Fine motor (fingers)
Balance (dance, gymnastics)

 

What sort of play do preschoolers (3-6 yr.) prefer?

Pretend play

 

What is preschooler (3-6 yr.) play characterized by?

Co-operative play (together)

 

School age (7-11 yr.) is characterized by the 3 C’s, what are they?

Creative (no coloring book, use blank paper)
Collecting
Competitive

 

Adolescents (12-18 yr.) “play” is?

Peer associated

 

Allow adolescents to be in each others rooms unless?

Contagious
Immunosupressed
Fresh post-op

 

If you’re being questioned over a drag and drop and you’re given an option that would require a doctors order assume that you have that order. But if an option is to call the doctor, you call first then give.

…

 

Best indicator of kidney function?

Creatnine

 

Creatnine norm?

0.6-1.2

 

INR monitors…

Coumadin/Warafin therapy

 

INR therapeutic level?

2-3

 

If the INR is over 4 you?

Hold all Coumadin/Warafin
Assess bleeding
Prepare to give K+
Call doctor

 

Potassium norm?

3.5-5.3

 

If the potassium is below 3.5 you?

Assess the heart
Prepare to give potassium
Call the doctor

 

If the potassium is high (5.4-5.9 high but still within the 5’s) you?

Hold potassium if in the IV
Assess the heart
Prepare to give D5W with insulin
Call the doctor

 

If the potassium is over 6 you…?

Assess
If negative effects present you call Rapid Response.
If no negative effects you do the same as “high but within the 5’s)

 

pH norm?

7.35-7.45

 

If the pH is under 6 you?

Assess vital signs
Call the doctor ASAP

 

BUN norm?

8-30

 

If the BUN is elevated cheack for?

Dehydration

 

How should you prioritize labs?

Based on what the level will do to the body and not the disease it’s associated with.

 

If you have a lab thats high and you don’t know why pick?

Dehydration

 

Hgb norm?

12-18

 

Hgb under 8 you?

Assess bleeding
Prepare blood
Call doctor

 

Bicarb (HCO3) norm?

22-26

 

CO2 norm?

35-45

 

CO2 is the 50’s you?

Assess respiratory status
Do pursed lip breathing
^ exhale time
DON’t give O2 if the above isn’t working call the doctor!

 

CO2 in the 60’s (respiratory failure) you?

Assess respiratory status
Do pursed lip breathing
Prepare for intubation
Call respiratory therapy
Call the doctor

 

Hct norm?

36-54

 

PO2 norm?

78-100

 

PO2 70-77 you?

Assess respiratory status
Give O2

 

PO2 below 60 you?

Assess respiratory status
Give O2
Prepare for intubation
Call respiratory therapy
Call the doctor

 

O2 sat norm?

93-100

 

O2 sat below 93 you?

Assess respiratory status
Give O2

 

BNP norm?

<100

 

BNP is a good indicator of what?

CHF

 

What is the best indicator of CHF?

ANF

 

ANF and BNP=

CHF

 

Sodium norm?

135-145

 

Sodium is ok if abnormal unless what occurs?

Change in LOC

 

WBC norm?

5,000-11,000

 

Absolute neutrophil count (ANC) norm?

500

 

CD4 norm?

< 200 is AIDS

 

If the WBC count is high this is called?

Leukocytosis

 

If the WBC is low it is called?

Leukopenia
Neutropenia
Agranulocytosis
Immunosupression
Bone marrow supression

 

If the WBC is low you should?

Follow strict handwashing
Shower BID with antimicrobial soap
Avoid crowds
Private room
No fresh flowers or potted plants
Low bacteria diet- no raw fruits/veggies, no undercooked meat.
No water drinking if its been sitting for longer then 15 minutes.
Vitals Q4H
Check WBC daily
Avoid reusable plates/silverware etc,

 

Platelets norm?

150,000-400,000

 

If platelets are below 90,000 you?

Check for bleeding
Place on bleeding precautions (thrombolytic precautions)

 

If platelets are below 40,000 you?

Prepare platelet transfusion
Call the doctor

 

RBC norm?

4-6

 

Reason for laminectomy is?

To treat nerve root compression.

 

3 P’s of nerve root compression (S/S) ?

Pain
Paresis= muscle weakness
Parasthesia

 

Knowing the location of a laminectomy is key to getting the ? right.

…

 

Cervical =

Neck

 

Thoracic =

Upper

 

Lumbar =

Lower

 

Pre-op cervical laminectomy’s most important assessment is?

1st breathing (rate and rhythm)
2nd arm and motor sensory

 

Pre-op thoracic laminectomy’s most important assessment is?

1st cough (uses abdominal muscles)
2nd bowel sounds

 

Pre-op lumbar laminectomy’s most important assessment is?

1st voiding ( when was last time, can they)
2nd leg motor and sensory.

 

The rule of ABC’s does not work in what area of health?

Neuro

 

What is the #1 post-op answer for the NCLEX?

Log roll the patient

 

Activity requirements/restrictions Q8H after laminectomy surgery?

Do not dangle (AKA sit on the side of bed)
May stand, walk and ly without restrictions
Don’t sit longer than 30 minutes

 

What post-op complication do you watch for with a cervical laminectomy?

Pneumonia

 

What post-op complication do you watch for with a thoracic laminectomy?

Pneumonia
Paralytic ileus

 

What post-op complication do you watch for with a lumbar laminectomy?

Urinary retention

 

For a laminectomy what incision site is more painful?

Hip site

 

For a laminectomy what incision has the most drainage/bleeding?

Hip site

 

For a laminectomy what incision site has the highest risk for infection?

50/50 equal

 

If being asked about a surgery and the length of time for restrictions your default answer should be?

6 weeks

 

Discharge teaching for a laminectomy?

Don’t sit for longer then 30 minutes for 6 weeks
Ly flat and log roll for 6 weeks
No driving for 6 weeks
Do not lift more then 5 lb. for 6 weeks

 

Permanent restrictions for a laminectomy?

Do not lift by bending at the waist
No crazy activities… jerky rides, horseback riding

 

Cervical laminectomy can’t…

Lift objects above the head.

 

Nageles rule for calculating a due date is?

1st day of the last menstrual period
Add 7 days
Subtract 3 months

 

Normal weight gain for pregnancy?

28 + or – 3 lb

 

1st trimester weight gain?

1 lb a month

 

2nd/3rd trimester weight gain?

1 lb a week

 

After week 12 you can subtract 9 to get appropriate weight gain.

…

 

Fundal height is not palpable until week?

12

 

The fundus is palpable at the naval at week?

20-22

 

If the fundus is not above the naval the baby is not?

Viable

 

Positive signs of pregnancy?

Fetal skeleton on X-ray
Fetal presence on ultrasound
Auscultation of FHR (heard at week 8, most likely at 10 and should be heard by 12)
Examiner palpates fetal movement

 

Probable/presumptive signs of pregnancy are?

All urine and blood tests

 

What is Chadwicks sign?

Cervical change to cyanosis (blue hue)

 

What is Goodells sign?

Cervical softening

 

What is Hegars sign?

Softening movesd from the cervix to the uterus.

 

How long do you go to the doctor for pregnancy once a month?

For 28 weeks.

 

How long do you go to the doctor every two weeks for pregnancy?

From week 28-36

 

How long do you go to the doctor for pregnancy every week?

From week 36-42

 

Is it normal to be slightly anemic during pregnancy?

Yes

 

Normal Hgb level in women is?

12-16

 

Hgb level in first trimester?

Can fall to 11 and it is normal.

 

Hgb level in second trimester?

Can fall to 10.5 and is normal.

 

Hgb level in the third trimester?

Can fall to 10 and is normal.

 

How do you treat morning sickness? (1st trimester)

Dry carbohydrate

 

How do you treat urninary incontinence during pregnancy? (1st and 3rd trimester)

Void Q2H

 

Treating dyspnea during pregnancy? (2nd and 3rd trimester)

Tri-pod position

 

How do you treat back pain in pregnancy? (2nd and 3rd trimester)

Pelvic tilt exercise

 

Always teach a pregnant women to pee how often from day of pregnancy to 6 weeks post partum?

Q2H

 

Truest most valid sign of labor is?

Regular contractions

 

Dilation is?

Opening of the cervix (0-10)

 

Effacement is?

Thinning of the cervix (0-100%)

 

Station is?

This refers to the baby’s presenting part (normally the head) to the mothers ischeal spine. So if the baby is above the ischeal spine they are given a – number, if they are below they are given a + number. + numbers are positive news and – numbers are negative news.

 

Engagement is?

Station 0

 

Lie is?

Relationship between the spine of the baby and the spine of the mom. Vertical (parallel) is ok, Tranverse (perpindicular) is bad.

 

Presentation is?

The part of the body that enters the birth canal first.

 

The first stage of labor is?

The labor part.

 

The second stage of labor is?

Delivery of the baby.

 

The third stage of labor is?

Delivery of the placenta.

 

The fourth stage of labor is?

Recovery (1st 2 hours after the placenta is delivered)

 

How often do you monitor during labor?

Q15min until the 2hr mark after placental delivery. Then Q1H.

 

The first stage of labor has how many phases?

3

 

What are the three phases of labor?

Latent, Active and Transition

 

Latent phase is?

0-4 cm dilated
Contractions are 5-30min apart
Lasting 15-30 sec.
They are mild

 

Active phase is?

5-7 cm dilated
Contractions are 3-5 min apart
Lasting 30-60 sec.
They are moderate

 

Transition phase is?

8-10 cm dilated
Contractions are 2-3 min apart
Lasting 60-90 seconds
They are strong

 

Contractions should be no longer then ____ and no closer then_____.

90 seconds and 2-3 minutes

 

How do you assess frequency of contractions?

Beginning of one contraction to the beginning of another.

 

Duration of a contraction?

Beginning to end of one contraction.

 

How do you assess the intensity of a contraction?

Palpate with one hand over fundus and with the fingertips.

 

How do you treat painful back labor?

Knee to chest position
You use your fist and press on the patients sacrum.

 

How do you treat prolapsed cord? 911!! OB emergency

Push head back in
Position in knee chest position or Trendelenburg

 

What interventions do you do for all other OB complications? (LION)

L-erft side position
I-ncrease IV
O-2
N-otify doctor
If Pitosin is running stop this first then LION

 

Do not give what type of pain medication to a women in labor if the medication is likely to peak when the baby is born?

Systemic medications (IM, IV, Oral)

 

Low fetal heart rate is ?

Bad you LION under 110

 

High fetal heart rate?

160 This is ok

 

Low baseline variability? (aka heart rate not changing)

Bad you LION

 

High baseline variability?

HR changing a lot. This is ok.

 

Late decelerations?

Bad (placenta) you LION

 

Early decelerations?

Head pressed on. This is ok.

 

Variable decelerations?

HR up or down, cord compression = BERY BAD

 

ACE of spades answer for OB?

Check fetal HR

 

If in OB its low or late you?

LION

 

If variable its?

Very bad and you push and position.

 

The second stage of labor and delivery is all about?

Order

 

So what do you do and in what order for the second stage?

Deliver the head
Suction 1st the mouth then the nose
Check for nuchle cord (cord around neck)
Deliver shoulders and body
ID band

 

During the third stage of labor and delivery (placental delivery) you do what two things?

Make sure it’s intact( if left in hemorrhage 1st infection 2nd)
Check for three vessels (2 arteries, 1 vein)AVA

 

What are the 4 things you do 4 times an hour for the 4th stage of labor?

VS- check for S/S of shock
Fundus- if boggy, massage. If displaced,void/cath
Perineal pad- excessive lochia= pad saturated Q15min 911
Roll on side and check the pad for bleeding.

 

The uterus should be like what after delivery?

Firm not boggy
Fundal height= days postpartum (3days= 3cm below naval)
Midline- if not catheterize

 

Lochia color rubra?

Red- rub it red

 

Lochia color serosa?

pink- rose pink

 

Lochia color alba?

White- albino white

 

Moderate lochia is?

4-6 inches on pad in one hour

 

Excessive lochia…

Saturated pad in 15 minutes

 

Extremity assessment post partum should check?

Pulses
Edema
S/S of thrombophlebitis- bilateral calf circumference is the best way to check. If they are equal its ok if not its positive for whichever calf is bigger)

 

Post partum assessment should include what?

Uterus
Lochia
Extremities

 

Milia is?

Distended sebacious glands which appear as tiny white spots on babys face.

 

Epsteins pearls are?

Small,white epithelial cysts on babys gums.

 

Mongolian spots are?

Bluish/black macules appearing over the buttocks and or thighs of darker skinned neonates.

 

Erythema toxicum neonatorum is?

Red papular rash on babys torso which is benign and disappears after a few days.

 

Hemangiomas is?

Benign tumor of the capillaries.

 

Cephalohematoma is?

Swelling caused by bleeding between the osteum and periosteum of the skull. This swelling does not cross suture lines.

 

Caput Succedaneum is?

Edematous swelling on the scalp caused by pressure during birth. This swelling may cross suture line. It usually disappears in a few day.

 

Hyperbilirubinemia is?

Normal, physiologic jaundice appears after 24 hours of age and disappears at about one week.

 

Vernix caseosa is?

Whitish, cheese like substance which covers the skin on an unborn baby.

 

Acrocyanosis is?

Normal cyanosis of the babys hands and feet which appears intermittently over the 1st 7-10 days.

 

Nevus/Nevi is?

The generic term for a birthmark.

 

What 2 newborn variations are you most likely to be tested on for the NCLEX?

Cephalohematoma and Caput Succedaneum

 

Tocolytics do what to labor?

Stop it

 

What are the two tocolytics?

Terbutaline= Brethine
Nifediopine= Procardia

 

SE for Terbutaline?

Maternal tachycardia
This drug is not good if a heart issue is already present.

 

SE of Nifedipine?

Headache and Hypotension (H&H)

 

Oxytocics do what to labor?

Start it

 

What are the two oxytocic’s?

Pitocin=Oxytocin
Cervidil= Prostaglandin

 

SE of Pitocin?

Can cause hyperstimulation (contractions longer than 90 sec. and closer then 2 min.)If FHR is less then 110 stop it, if FHR is normal you slow it.
Used also for PP Hemorrhage.

 

SE of Cervidil?

Effacement which leads to contractions.

 

What are the two neonatal lung medications?

Betamethasone
Survanta

 

How do you give Betamethasone?

To the mom
Before delivery
IM

 

SE of Betamethasone?

Increase in mom’s glucose, so monitor blood sugar.

 

How do you give Survanta?

To the baby
After delivery
By inhalation

 

Humulin 70/30 is what?

70% N insulin and
30% R insulin

 

When drawing up insulins its?

RN (regular then N) draw what you are RN)

 

If your are pressurizing for drawing up insulin you?

Draw what you are backwards. NR—-> RN

 

For injections an IM needle must be?

A 1 in both gauge and length.

 

For injections SUBQ needles must have?

A 5 in both gauge and length.

 

What routes can you give Heparin?

IV or SUBQ

 

How quickly does Heparin work?

ASAP

 

What do you monitor if on Heparin?

PTT

 

Antidote for Heparin is?

Protamine Sulfate

 

Heparin is what pregnancy class?

C

 

How can Coumadin be given?

Oral only

 

How long does it take for Coumadin to work?

3-5 days

 

What do you monitor in Coumadin?

Pt-INR(this is only for Coumadin)q

 

What is the antidote for Coumadin?

Vitamin K

 

What pregnancy class is Coumadin?

X

 

All K+ wasting diuretics end in?

X… If it ends in X its X’s out K+ everything else it K+ sparing diuretics.

 

What is Baclofen(Lioresil, Flexeril)?

Muscle relaxer

 

Baclofen(Lioresil, Flexeril) SE?

Muscle weakness and drowsiness

 

What should you teach a patient taking Baclofen(Lioresil, Flexeril)?

Don’t drive/ operate machinery
Don’t drink alcohol
Don’t care for children under 12

 

What is the saying that can be used to help remember Baclofen(Lioresil,Flexiril)?

When you’re on Baclofen you’re on your back loafin.

 

A 0-2 yr old is in what Paiget stage?

Sensorimotor

 

A 3-6 yr old is in what Piaget stage?

Pre-operational

 

A 7-11 yr old is in what Piaget stage?

Concrete operation (think of a 7-11 with concrete around it)

 

Piaget’s Stage: 12-15 years old

Formal Operations

 

Piagets sensorimotor stage is characterized by?

Present oriented
Only think about what they SENSE or are DOING now.

 

As a nurse when, what and how do you teach a child in sensorimotor stage?

Teach when you’re doing it
What you’re doing to them
Do it verbally

 

Piagets pre-operational stage is characterized by?

Fantasy oriented
Illogical
No rules

 

As a nurse when, what and how do you teach a child in the pre-operational stage?

Teach: the day of (to avoid nightmares)
What: you’re going to do
How: use PLAY

 

Piagets concrete operations stage is characterized by?

Rule oriented
Live and die by the rules
Cannot abstract

 

As a nurse when, what and how do you teach a child in the concrete operations stage?

Teach them ahead of time
What you’re going to do
Use visual and audio and use age appropriate reading

 

At what Piaget stage can you teach a skill like how to draw up insulin?

Concrete operations

 

Piagets formal operations stage can be taught like?

An adult

 

For prioritization the question will give what 4 pieces of information?

Age
Gender
Disease
Modifying phrase

 

For a prioritization question the most important information is?

The modifying phrase

 

For a prioritization question what 2 pieces of information do not matter?

Age and gender

 

What are the four rules of prioritization?

Acute beats chronic
Fresh post-op(12hr.) beats medical or other surgical.
Unstable beats stable
The more vital the organ the higher the priority(use only as a tie breaker)

 

What is the best rule out of all 4 for prioritization?

#4

 

What makes a patient stable? (7)

Chronic illness
Over 12 hr post op
Local or regional anesthesia
Unchanged assessment
Phrase “to be discharged”
Lab values A or B
Typical S/S for the disease they have or what they are receiving treatment for.

 

What makes a patient unstable? (7)

Acute illness
Post-op less than 12 hr
General anesthesia
Changed assessment
Phrase “newly admitted” or “newly diagnosed”
Labs C & D
Unexpected S/S

 

What 4 things are always considered unstable?

Hemorrhage
Hypoglycemia
Fevers over 104*
Pulselessness and breathlessness

 

What are the main 6 organs in prioritized order?

  1. Brain
    2. Lung
    3. Heart
    4. Liver
    5. Kidney
    6. Pancreas

 

What do you not delegate to a family member?

Safety responsibilities-” can you watch your dad really fast while I grab something.”

 

Family can only do what you ____ them for the patient?

Teach

 

If another staff member is doing something illegal you?

Tell the supervisor.

 

What do you do if another staff member is placing the patient in physical or psychological harm?

Intervene and take over.

 

What do you do if a staff members behavior is legal, not harmful but just inappropriate?

Counsel them later at a better time.

 

The ACE of spades answer for nutrition is to either pick ____ or _____.

Chicken
Fish

 

Never choose _______ as a food for children.

Casserol

 

For a toddler pick ______ food.

Finger

 

For a preschooler ____ meal a day is ok!!!

1

 

If you know what a particular drug does pick a SE in the ______ body system.

Same

 

If you have no idea what a drug is check to see if it is ___. If it is pick a _______ SE.

PO
GI

 

Ace of Spades answer for OB?

Check the FHR.

 

What is the first thing you assess in a Med-Surg situation?

L.O.C. = Bob, Bob, Bob are you ok????

 

What is the first thing you do in a Med-Surg situation?

Airway

 

For Peds patients, when in doubt, call it___________.

Normal

 

For Peds when in doubt pick?

The older age.

 

For Peds when in doubt pick the?

Easier task.

 

In Peds always give?

More time

 

Empathy question have?

A quote in the question and a quote in the answer.

 

In psych choose the answer that reflects the _______ and not the _______ they said.

Feelings
Words

 

 

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Mark Klimek‘s Impact on Nursing Licensure Exam Preparation

If you’re looking for tips to pass the nursing licensure exam, then you should check out the review of Mark Klimek. He is a former nurse and a top-notch reviewer who can help you pass the exam the first time. Read on to see his reviews and testimonies from people who have already passed.

Mark Klimek’s Nursing Licensure Exam Review

Aside from the obligatory passing grades, obtaining a nursing license comes with its own set of challenges. The National Council of State Boards of Nursing (NCCBN) is tasked with evaluating the competence of aspiring nurses to ensure safe care is delivered. Having a nursing school diploma isn’t enough, you also need to know the NCLEX test well. Thankfully, there is a plethora of resources to help you on your quest to become a certified nurse. This includes reviews, seminars and courses, spanning all levels of experience.

For starters, the NCCBN uses computerized adaptive testing to evaluate the competence of prospective nurses. In addition to providing quality review services, it has a mission statement stating that it will “never deviate from its mission to assure the safety of the public.”

One of the more interesting aspects of Mark Klimek‘s offerings is his willingness to be flexible with his schedule. His sessions are typically comprised of a handful of students, many of whom attend only the course that suits their needs. Some sessions are free, while others cost a dime. Nevertheless, the best part is that you can take the NCLEX review for a spin as often as you wish. And you get to keep the review material!

Testimonials from Past Participants

The best part about it is that you don’t have to pay for it. Mark isn’t stingy. If you aren’t in the market for a full service course, you can take a stab at his introductory minicourses. Getting started is simple. Plus, Mark is a big fan of hands-on learning. As such, you will be working one-on-one with a qualified instructor who is more than willing to help you get your nursing career on the right foot. This is the type of partnership that will set you up for life.

Not all of Mark’s offerings are created equal. For example, his one-on-one courses aren’t available on a regular basis. That said, his introductory minicourses are available on an as-needed basis. In short, if you want to shave some time off your training schedule, entrust your nursing career to the man who knows his stuff. Luckily, the man has been around the block a few times and is more than willing to make your NCLEX experience a memorable one. Besides, he’s a genuinely nice guy. He’s also a bona fide geek who can answer your most pressing questions, no matter how ridiculous they may be.

Tips for Success on the Nursing Licensure Exam

If you are considering a career in nursing, you must take the National Council Licensure Examination (NCLEX). The test demonstrates that you have a firm grasp of nursing concepts. Once you pass, you’re on your way to a rewarding nursing career. To succeed on the exam, you need to put in a lot of time and effort.

The test consists of several different types of questions. Some are multiple-choice. Others may have exhibits such as charts or graphics. Still others ask you to arrange procedures in a certain order.

A few practice exams are recommended before the actual exam. This helps to ease test anxiety and increase your confidence. You’ll also find that taking practice exams allows you to identify topics to study.

Having a set study schedule is crucial to success. Make sure that you are dedicating enough time to each study period. Take advantage of your study time by reading every question and reviewing each incorrect answer.

Try not to obsess about the number of questions you get right. Remember that the exams are only as difficult as you make them. Avoid cramming the night before the test. Instead, plan to take the test during the day.

Before you take the test, ensure that you have a quiet and comfortable place to study. Studies show that meditation and yoga can help with focus. Getting adequate sleep and eating a healthy diet can also help with memory.

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]]> https://1filedownload.com/mark-klimek-alternative-views-of-energy/feed/ 0 Mark Klimek Lectures 1 To 12 Nursing Notes https://1filedownload.com/mark-klimek-lectures-1-to-12-nursing-notes-2/ https://1filedownload.com/mark-klimek-lectures-1-to-12-nursing-notes-2/#comments Sat, 10 Sep 2022 20:49:25 +0000 https://1filedownload.com/?p=281291

 

GUIDE • Mark Klimek’s Lecture

Lecture 1— Acid-Base Balance Dumping/HH
Ventilators Electrolytes: K+, CA, MG,
and NA
Lecture 2— Alcohol TX for HyperKalemia
Wernicke
Overdose and Withdrawal Lecture 7— Thyroid (Hyper-, Hypo-)
S/Sx Adrenal Cortex (Addison
Aminoglycosides Disease, Cushing)
Peak and Trough Toys
Laminectomy
Lecture 3— Drug Toxicities (Lithium,
Lanoxin, Dilantin, Bilirubin, Lecture 8— Lab Values
Aminophylline) Five Deadly Ds
Kernicterus Neutropenic Precaution
Dumping/HH
Electrolytes: K+, CA, MG, Lecture 9— Psych Drugs
and NA Tri
TX for HyperKalemia Benzo
MAOI
Lecture 4— Crutches Lithium
Canes Prozac
Walkers Haldol
Delusions Clozaril
Hallucinations Zoloft
Psychosis
Psychotic and Non-Psychotic Lecture 10— Maternity and Neonatology
Hallucination
Illusion Lecture 11— Fetal Complications
Delusion Stages of Labor
Assessments
Lecture 5— Diabetes Mellitus Variations for NB
Diabetes Insipidus Maternity Meds
SIADH Medication Hints
Insulin Psych Tips
DKA Operational Stages
HHNK
Lecture 12— Prioritization
Lecture 6— Drug Toxicities (Lithium, Delegation
Lanoxin, Dilantin, Bilirubin, Staff Management
Aminophylline) Guessing Strategies
Kernicterus

Lecture 1 • Mark Klimek • 92:21

Acid/Base Balance (Start times: 30:00)

In order to solve acid-base disorders, it is important to know the normal values for pH, CO2 and HCO3 (bicarbonate), which are shown below

  • pH 7.35 to 7.45
  • CO2 35 to 45
  • HCO3 22 to 26

The first value to look at in an acid-base disorder is the pH

  • If pH is <7.35, the acid-base imbalance is acidotic
  • If pH is <7.45, the acid-base imbalance is alkalotic

Now, to determine if the imbalance is metabolic or respiratory, determine whether HCO3 goes in the same or opposite direction with pH

  • Rule of the Bs: If pH and Bicarb move both in the same direction, then the acid-base imbalance is metabolic … Otherwise, it is respiratory

Example #1

  • pH 7.3 Acidotic
  • HCO3 20 Metabolic
  • This is an example of metabolic acidosis

Example #2

  • pH 7.58 Alkalotic
  • HCO3 32 Metabolic
  • This is an example of metabolic alkalosis

Example #3

  • pH 7.22 Acidosis
  • HCO3 35 Respiratory
  • This is an example of respiratory acidosis

As the pH goes, so goes my patient, except for Potassium … That means

  • If pH is low, everything is low, except potassium
  • If pH is high, everything is high, except potassium

If pH goes over 7.45, this is alkalosis

  • Therefore everything is up: tachycardia, tachypnea, HTN, seizures, irritability, spastic, diarrhea, borborygmi (increase bowel sounds), hyperreflexia (3+, 4+)
  • However, potassium is opposite. Therefore, hypokalemia
  • What is the nursing intervention?
    • Pt need suctioning because of seizures

If pH goes below 7.35, this is acidosis

  • Therefore, everything is down: bradycardia, constipation, absent bowel sounds, flaccid, obtunded, lethargy, coma hyporeflexia (0, 1+), bradypnea, low BP
  • However, potassium is high (hyperkalemia)
  • What is the nursing intervention?
    • Pt needs to be ventilated with an Ambu bag—respiratory arrest

So, remember that “MAC Kussmaul” is the only acid-base imbalance to cause Metabolic ACidosis with Kussmaul respirations

Causes of Acid/Base imbalance

First ask yourself, “Is it LUNG? … If yes, then it is respiratory

  • Then ask yourself, “Are they overventilating or underventilating?
    • If UNDERventilating, then pick acidosis—pH is under 7.35
    • If OVERventilating, then it is alkalosis, pH is over 7.45

What type of acid-base derangement is present in the following condition?

  • In labor?
    • Respiratory alkalosis … Overventilating—pH increases … Alkalosis)
  • Drowning?
    • Respiratory acidosis … Underventilating—pH decreases … Acidosis
  • Pt is on PCA (patient-controlled anesthesia) pump?
    • Ventilation is down … Respiratory acidosis

If it is not LUNG, then it is metabolic. If the patient has prolonged gastric vomiting or suction (sucking out acid), pick alkalosis

  • For everything else that isn’t lung, pick metabolic acidosis

So, when you don’t know what to pick, pick metabolic acidosis

Tip

  • Set your default setting to Metabolic Acidosis
  • Always pay attention to modifying phrase rather than original noun

Figure 1. Patient- controlled anesthesia (PCA) pump.

Ventilator

A ventilator is a machine designed to move breathable air into and out of the lungs, aids patients who are physically unable to breathe, or breathing insufficiently to breathe … A ventilators is equipped with a high and a low-pressure alarm

High pressures alarms are always triggered by increased resistance to air flow. Look for obstructions, i.e.,

  • Kinks in tubing … Solution: unkink the tube
  • Condensed water in the dependent tube … Solution: empty it
  • Mucus plugs … Solution: Ask pt to turn, cough, deep breathe; or suction the tubing PRN

What is the appropriate order to address high pressure alarm in a mechanical ventilator?

  • (1) Unkink. (2) Empty water out of tubing. (3) turn pt, ask pt to cough or deeply breathe, and (4) suction

Low pressures alarms are always triggered by decrease in resistance. This can be caused by

  • Main tubing disconnection
  • O2 sensor tube disconnection
  • In both cases, reconnect the disconnected tubing unless tube is on floor … Bag pt and call Respiratory Therapist

The ventilator may be set too high or too low

  • Setting is too high … Pt is overventilated
    • Respiratory Alkalosis … Panting
  • Setting is too low … Pt is underventilated
    • Respiratory Acidosis … Pt is retaining CO2

Question

The physician wants to wean pt off vent in the morning. At 6 am, the ABGs say respiratory acidosis. What would you do next?

  • Notify the physician that the pt is not ready to be weaned off the respirator
    • Pt is is respiratory acidosis, which means that he is underventilated … Therefore not ready to be weaned off the ventilator
    • If pt were in respiratory alkalosis (overventilated), he should be ready to be weaned off

Lecture 2 • Mark Klimek • 101:54

Alcoholism

  • The #1 psychological problem is DENIAL

The title of this section is alcoholism. However, this rule can be used for any abuse situation

  1. So, what it the number 1 psychological problem in child abuse? … In gambling?

… In cocaine abuse? … In spousal abuse? … In elder abuse?

a. The answer is denial

  • How do you respond/treat to pts in denial?
    • Confront them by pointing out the difference b/w what they say and what they do
    • For instance, say something like: “Ok, you say you’re not an alcoholic but it is 10 a.m. and you’ve already had a 6 pack” … It is not the same as aggression. Don’t attack the person
    • Good answer has “I” … Bad answer has “YOU”
    • One place where denial is ok—loss and grief Stages of grief are “DABDA”—Denial, anger, bargaining, depression, acceptance
    • So when the question is about pt in denial, pay attention to whether you are dealing with

loss or abusive situation Support = Loss Confront = Abuse

Dependency vs. Co-dependency

  • The #2 psychological problem is Dependency or Co-Dependency
  • Dependency: when the get the significant other to do things or make decisions for them
    • The abuser is dependent
  • Co-dependency: when the significant other derive self-esteem for doing things or making decisions for the abuser
    • The significant other is the co-dependent

Dependency and co-dependency has a symbiotic, yet a pathological relationship

    • The dependent pt get a free ride on the co-dependent
    • The co-defendant pt feels good from “doing stuff” for the abuser
  • How do you treat dependency/codependency?
    • Dependent pts are “abusers” … Confront them
    • Co-dependent pts have self-esteem issues … Teach pts how to set limits and enforce them
    • Agree in advance on what requests are allowed then enforce
    • Teach significant other to say no
    • Work on self-esteem on the co-dependent person

Manipulation

  • Manipulation is when the abuser gets the significant other to do things or make decisions that are not in the best interests of the significant other
    • The nature of the act is dangerous and harmful to the significant other
  • How is manipulation like dependency?
    • In both situations the dependent person gets the co-dependent person to do things or make decisions
    • If what the significant other is being asked to do is not inherently dangerous and harmful, then this is dependency/co-dependency
    • However, if the significant other is being asked to do something inherently dangerous and harmful, then this is manipulation
  • Manipulation? Set LIMITS and Enforce them

Examples

Determine if either one of these situations is dependent/co-dependent problem or a manipulation problem

  • A 49-year-old alcoholic gets her 17-year-old son to go to the store and buy alcohol for her.
    • The mother is manipulating the son
    • This is an illegal act = Harmful
    • Dependency … There are 2 patients
    • The dependent has a denial issue
    • The co-dependent has a self-esteem issue
  • A 49-year-old alcoholic asks her 50-year-old husband to go to the store and buy alcohol for her.
    • This is not illegal for the husband to buy alcohol
    • This a dependency/co-dependency situation
    • Manipulation … There is 1 patient—no self-esteem issues
    • Easier to treat because no one like to be manipulated

Wernicke (Korsakoff) Syndrome

Typically, Wernicke and Korsafoff are 2 separate disorders. The NCLEX however bundles the 2 as 1 condition

  • Wernicke is an encephalopathy
  • Korsakoff is a psychosis
  • Wernicke and Korsafoff tend to go together

Wernicke and Korsafoff

  • Psychosis induced by Vitamin B1, thiamine deficiency
  • This is a situation the pt looses touch with reality due to vit B1 deficiency
  • The primary S/Sx are amnesia (memory loss) and confabulation (making up stories)
    • Confabulation—The lies for this pts are just as real as reality

How do deal with a pt with Wernicke and Korsafoff who is confabulating about going to a meeting with Barack Obama this morning?

  • Redirect the pt to something he can do
    • For instance, tell pt something along that line: “Why can we go watch TV to see what is on the news today”

Characteristics of Wernicke and Korsafoff syndrome

  1. Preventable … Take B1
  2. Arrestable (stop it from getting worse) … Take B1
  3. Irreversible (70%) … Will kill brain cells

Antabuse and Revia (Disulfiram)

  • Antabuse—Alcohol deterrent
  • Revia—Antidote
  • Aversion (strong hatred) Therapy—a type of behavior therapy designed to make a patient give up an undesirable habit by causing them to associate it with an unpleasant effect
    • Works in theory better than in reality
  • Onset (how long it takes to start working) and duration (how long it lasts) of effectiveness of Antabuse/Revia is 2 weeks
    • For instance, if pt will be at a function and would like to drink, the pt must be on Antabuse/Revia at least 2 weeks prior to the event
  • Patient teaching
    • Teach pt to avoid all forms of EtOH. Not doing so may lead to symptoms of n/v, even death
    • Teach them to avoid the followings items as they contain alcohol … Mouth wash, cologne, perfume, aftershave, elixir, most OTC liquid medicine, insect repellant, hand sanitizer, vanilla extract (can’t have cupcake with unbaked icing)

On the exam, do not pick the Red Wine vinaigrettes … It does not have alcohol in it

Overdose and Withdrawal

First thing you ask in an overdose question is: Is it an Upper or a Downer?

  • This is because every abuse drug is either an Upper or a Downer
  • However, laxative abuse in the elderly is neither an Upper nor a Downer

Upper Downer

  • Caffeine
  • Cocaine
  • PCP/LSD (psychedelics/hallucinogens)
  • Methamphetamines
  • Adderall
  • Memorize these five for the NCLEX

Signs and Symptoms

  • Things go UP!
  • Euphoria, seizures, restlessness, irritability, hyperreflexia (3+, 4+), tachycardia, increased bowels
  • There are over 135 drugs that are downers
  • If it is not an upper, it is a downer

Signs and Symptoms

  • Things go DOWN!
  • Lethargic, respiratory depression/arrest, constipated, etc.

(borborygmi), diarrhea

What are the highest nursing priority to anticipate in an Upper or Downer?

  • Upper: The highest priority to anticipate in an Upper is suctioning due to seizures
  • Downer: The highest priority to anticipate in a Downer is intubation/ventilation due to

respiratory arrest

Example

One of your pt is “high on cocaine.” What is critically important to assess?

  • Having a RR of 12 is not a critical measurement to assess for that pt
  • However, assessing for reflexes (3+ or 4+), irritability, borborygmi (increased bowel sounds), or increased temperature would be more appropriate
    • The “ABC rule” does not apply here … In fact, the pt’s ABC in cocaine toxicity is unremarkable

After you know that the drug in question is an Upper or a Downer, the second question you should ask yourself is whether it is an Overdose or a Withdrawal

  • Overdose and withdrawal have the opposite effects

Overdose

 

Overdose on an Upper Overdose on a Downer

 Too much  Too little

Withdrawal

 

Withdrawal on an Upper Withdrawal on a Downer

 

 Too little  Too much

Question

The driver of a squad car calls the ER and says he is bringing a pt who in ODed on cocaine. What do you expect to see? … Select all that apply

  • Pt ODed on Upper OD … Expect to se Too much
    • First question: Upper or a Downer?
    • Second question: Overdose or Withdrawal?
    • S/Sx would be: Irritability, 4+ reflexes, borborygmi, increased temperature, etc.

Question

The same pt is withdrawing from cocaine … Same question

  • This pt is an Upper in Withdrawal = Too little
  • Therefore, respiratory is under 12, pt is difficult to arouse, give them Narcan

Drug Abuse in the Newborn

Always assume intoxication, not withdrawal at birth, in a newborn less than 24 hours after birth. 24 hours or more after birth, you can assume the newborn is in withdrawal

Question

You are caring for an infant born to Quaalude addicted mother 24 hours after birth. Select all that apply

  • Overdose/withdrawal condition … Ask the following 2 questions
    • Is it an Upper or a Downer? … We don’t what it is because it is a “Quaalude” (it is likely a Downer)
    • Is it Overdose or Withdrawal? … 24 hours after birth (Withdrawal)
    • A Downer in Withdrawal = Too much
    • S/Sx = Difficult to console, seizure risk, shrill, high-pitched cry, exaggerated startle reflex

Alcohol Withdrawal Syndrome vs. Delirium Tremens

Alcohol Withdrawal Syndrome and Delirium Tremens are not the same

  • Every alcoholic goes through alcohol withdrawal approximately 24 hours after the person stops drinking
  • However, less than 20% of alcoholics in alcohol withdrawal syndrome progress to delirium tremens … Delirium tremens occurs about 72 hours after the person stop drinking
  • Alcohol withdrawal syndrome always precedes delirium tremens; however, delirium tremens does not always follow alcohol withdrawal syndrome

Alcohol Withdrawal Syndrome Delirium Tremens

  • Occurs after 24 hours after drinking

 Non-life threatening to self and others

Nursing Care Plan

  • Regular diet
  • Semiprivate room, anywhere on the unit
  • Pt is up ad lib (Pt is free to move around as desired)

 No restraints

  • Occurs after 72 hours after drinking

 Life threatening to self and others

Nursing Care Plan

  • NPO (seizures) or clear liquid diet
  • Private room, near nursing station
  • Restricted bed rest (Pt is not free to move around as desired—no bathroom)

 Restraints (vest or 2-point lock letters)

Note

  • “Up ad lib” or “up ad liberum” means pt may have activity or free to move around as desired any time
  • 2-point lock letters restraints: Restraints in 1 upper and the contralateral lower extremities. Release and secure upper arm first, and then release and secure the foot. Switch extremities every 2 hours
  • Give both anti-HTN medication, tranquilizer, multivitamin containing vit B1

Question

So what two situations would respiratory arrest be a priority?

  • Overdose of a Downer
  • Withdrawal of an Upper

Question

Which pts would seizure be a risk for?

  • Overdose of an Upper
  • Withdrawal of a Downers

Aminoglycosides (Top 5 most tested drugs)

Aminoglycosides are the big guns of ABXs (antibiotics)— use them when nothing else works. Aminoglycosides are unsafe at toxic levels and safety then becomes an issue. They are the 5th most tested drugs on the NCLEX

The most tested drugs on the NCLEX are:

  • Top 5
    • Psychiatric
    • Insulin
    • Anticoagulant
    • Digitalis
    • Aminoglycosides
  • Others
    • Steroids
    • Beta-blockers
    • Calcium channel blockers
    • Pain medications
    • Obstetrics medications

“A Mean Old Mysin” = Aminoglycosides

Would be used to treat serious, resistant, life-threatening, Gram negatives infections

  • So, treat a mean old infection with a “Mean Old Mycin”
    • Examples are: TB, septic peritonitis, fulminating pyelonephritis, septic shock, infection from third degree wound covering >80% of the body
    • However, sinusitis, otitis media, bladder infection, viral pharyngitis, and strep throat are not old mean infections and are not treated with a mean old mycin

All aminoglycosides end in Mycin

  • Gentamycin, Vancomycin, and Clindamycin, Streptomycin, Cleomycin, Tobramycin
  • Not all drugs ending in mycin are aminoglycosides
    • Azithromycin, Clarithromycin, Erythromycin … All have THRO in the middle … So, THRO them off the “Mean Old Mycin” list

What are toxic effects?

  • Mycin—Sounds like Mice (Think ears) … Monitor hearing (#1), balance, tinnitus (ringing of the ear, CN8 toxicity)
  • The human ears are shaped like a kidney so another toxic effect of aminoglycosides is nephrotoxicity (Toxic to the kidneys)
    • Therefore, monitor Creatinine

What would be your answer if in a question, you have to choose which is the best between 24-hour creatinine and serum creatinine?

  1. Creatinine = Best indicator of kidney function
  2. 24-hour creatinine clearance is better than Serum creatinine

The figure 8 drawn inside the ear should remind you of of 2 things They are toxic to CN8

Administer them q8 hour

Do not give Mean Old Mycins PO because they are not absorbed, and therefore would not have any systemic effects

There are 2 cases where Mean Old Mycins are given PO

  • Hepatic encephalopathy (or hepatic coma) where ammonia level gets too high
  • Pre-op bowel surgery: to sterilize the bowel before surgery
  • In both cases, the ABX stays in the gut (not absorbed), sterilizes the bowel, and would not be toxic

The #1 action of an “oral mycin” … Sterilize the bowel

    • Who can sterilize my bowel?

Neo Kan

    • Neomycin and Kanamycin

“A Mean Old Mycin” is given IM or IV because it is excreted in feces and not absorbed in the GI tract. It is used in hepatic encephalopathy to kill E. coli, and bowel surgery (to sterilize the bowel).

Note

E. coli in the gut is the #1 producer of ammonia, which at toxic levels, leads to encephalopathy

Troughs and Peaks

  • Troughs is when drugs is at their lowest concentration in the pt’s blood
  • Peaks is when drugs is at their highest concentration in a pt’s blood

“TAP” Levels

  • A method to remember what is done before or after, when dealing with a medication with troughs and peaks
  • “TAP”—Trough, Administer, Peak
    • Trough before drug administration
    • Peak after drug administration
    • Trough and Peak levels are drawn because of a drug’s narrow therapeutic window or index
    • Narrow therapeutic window or index means that there is a small difference in what works and what kills

Which one of the following medications would “trough and peak” important?

Note

1. Draw TAP on Mean Old Mycins because of their narrow therapeutic index

  • Lasix (furosemide)
    • Smaller dose: 5 or 10
    • Larger dose: 80 or 120
  • Digitalis (digoxin)
    • Smaller dose: 0.125
    • Larger dose: 0.25
    • Would draw “TAP” (Trough, Administer, Peak) on digitalis

When to Draw a Through and a Peak

  • Both Trough and Peak are not medication-dependent
  • The trough, it is always drawn 30 minutes before next dose
  • For the peak, it depends on the route
    • Peak SubL 5 to 10 minutes after drug is dissolved
    • Peak IV 15 to 30 minutes after drug is finished (bag empty)
    • Peak IM 30 to 60 minutes
    • Peak SubQ Depends on insulin (See diabetes lecture)
    • Peak for PO Not necessary, not tested

Question

You give 100 mL of a drug at 200 mL per hour (the drug takes 30 minutes to run). If you hang the drug at 10 a.m., it will finish running at 10:30 a.m. When will the drug peak?

Note

  • The same drug given by 2 different routes at the same time will have different peaks
    • Morphine
  • However, 2 different drugs given at the same time and route (IV) will peak together
    • Morphine and amphetamine

1. 10:15 a.m.

2. 10:30 a.m.

3. 10:45 a.m.

4. 11:00 a.m.

Answer: Two right answers—pick 11:00 a.m.

In this case, play the “Price Is Right”—go with the highest time w/o going over

Lecture 3 • Mark Klimek • 111:11

Calcium Channel Blockers

CCBs (Calcium channel blockers) are like Valium for the heart

They relax and slows down the heart

  • In other words, CCBs have negative inotropic, chronotropic, dromotropic effects on the heart

(+) Inotropy, Chronotropy, Dromotropy (–) Inotropy, Chronotropy, Dromotropy

 

Positive inotropy

  • Increase cardiac contractile force  Ventricles empty more completely  Cardiac output improved

Positive chronotropy

  • Increase rate of impulse formation at SA

node  Accelerate heart rate

Positive dromotropy

  • Increase speed that impulses from SA node travel to AV node (increase conduction velocity)

Negative inotropy

  • Weaken/decrease the force of myocardial contraction

Negative chronotropy

  • Decrease rate of impulse formation at the

SA node  decelerate heart rate

Negative dromotropy

  • Decrease speed that impulses from SA node travel to AV node (decrease conduction velocity)

When do you want to relax and slows down the heart? … To treat “A, AA, AAA”

  • Antihypertensive
  • AntiAnginal drugs (decreasing oxygen demand)
  • AntiAtrialArrhythmia

Side Effects

Headache and hypotension

Name: ends in “dipine” … Not “pine”

  • Also, verapimil, Cardizem (diltiazem)
  • Cardizem (diltiazem) is given continuous IV drip

What are the parameters to assess before putting a pt on CCBs?

  • Assess for BP
  • Hold if SBP <100

Cardiac arrhythmias

  • Knowing how to interpret rhythm
  • Must know the following 4 cardiac rhythms by sight

Normal Sinus Rhythm

  • There is a P wave, followed by a QRS, followed be a T wave for every complex
  • Peaks of the P wave is equally distant to the QRS, and fall within 5 small boxes

Ventricular Fibrillation

  • No pattern

Ventricular Tachycardia

  • Sharp peaks with a pattern

Asystole

  • A flat line

If the question mentions

  • QRS depolarization = Ventricular

There are 3 levels of nursing knowledge

  1. Stuff you need to know
  2. Stuff that is nice to know
  3. Stuff that is nuts to know
  • P wave = Atrial

The 6 rhythms most tested on the NCLEX

  1. A lack of QRS complexes is asystole—a flat line
  2. P waves (atrial) in the form of saw tooth wave = atrial

flutter

  1. Chaotic P wave patterns = atrial fibrillation (a-fib) (Chaotic: word used to describe fibrillation)
  2. Chaotic QRS complexes = ventricular fibrillation (v-fib)
  3. Bizarre QRS complexes = ventricular tachycardia (v-tach) (Bizarre: word used to describe tachycardia)
  4. Periodic wide bizarre QRS complexes = PVCs (Salvos of PVCs = A short runs of v-tach)

PVCs (premature ventricular contractions) are usually low priority

  • However, elevate them to moderate priority if under the following 3 circumstances
    • There are 6 or more PVCs in a minute
    • More than 6 PVCs in a row
    • R on T phenomenon (a PVC falls on a T wave)
  • PVCs after an MI is common and is a low priority

Lethal arrhythmias are high priority and will kill a pt in 8 minutes or less. They are:

  • Asystole and V-fib (ventricular fibrillation)
  • Both rhythms produce low or no cardiac output (CO), without which there is inadequate or no brain perfusion. This may lead to confusion and death

Potentially Lethal Cardiac Arrhythmia

  • V-tach (ventricular tachycardia) is a potentially lethal cardiac rhythm but it has a CO

How would a pt with or without CO presents?

  • CO is absent = there is no pulse
  • CO is present = there is a pulse

Treatment of PVCs and V-tach

  • Ventricular = Lidocaine
  • Both are ventricular rhythms
  • Treat with Lidocaine
  • Amiodarone is eventually the NCLEX board will want as answer

Supraventricular arrhythmias are Atrial arrhythmias (supra = above) Treatments are “ABCDs”

  • Adenocard (Adenosine) … Fast IV push (push in less than 8 seconds and 20 mL NS flush right after) … These pts will go into asystole for about 30 seconds and out of it
  • Beta-blockers (end in -olol)
  • CCBs
  • Digitalis (digoxin), Lanoxin (another digitalis analog)

Beta-blockers have negative inotropic, chronotropic, dromotropic effects on the heart. They treat “A, AA, AAA”

Tx: Atrial arrhythmias

  • Adena
  • Beta
  • Calcium
  • Dig

Tx: Ventricular arrhythmias

  • Lidocaine
  • Amiodarone
  • Antihypertensive
  • AntiAnginal drugs (decreasing oxygen demand)
  • AntiAtrialArythmia
  • Side Effects = Headache and hypotension

Treatment of V-fib and Asystole

  • Defib for V-fib (Defib = defibrillate = Shock em!)
  • Epinephrine and Atropine for Asystole

Chest Tubes

Purpose: to reestablish negative pressure in the pleural space … Negative pressure in the pleural space makes thing stick so that the lung expands when the chest wall expands

  • Pleural space is the space between the lung (visceral pleura) and the chest wall (parietal pleura)
  • In a pneumothorax, chest tube removes air
  • In a hemothorax, chest tube removes blood
  • In a hemopneumo- thorax, chest tube removes air and blood

Question

A chest tube is placed in a pt for a hemothorax (blood). What would you (the LPN) report to the nurse? Or, what would you (the RN) report physician?

    1. Chest tube is not bubbling
    2. Chest tube drains 800 mL in the first 10 hours
    3. Chest tube is not draining
    4. Chest tube is intermittently bubbling

What is the chest tube not supposed to do? The chest tube is supposed to drain instead of bubbling

  • Therefore answer (c) is the right answer.

Question

A chest tube is placed in a pt for a pneumothorax (air). What would you (the LPN) report to the nurse? Or, what would you (the RN) report physician?

  1. Chest tube is not bubbling
  2. Chest tube drains 800 mL in the first 10 hours
  3. Chest tube is not draining
  4. Chest tube is intermittently bubbling

With a pneumothorax, bubbling is expected

  • Therefore, (a) is a good answer choice
  • Since this is a pneumothorax, not too much blood is expected
  • Consequently, 800 mL of blood over 10 hours (80 mL per hour) is too much blood and needs to be reported to the nurse or the physician

Also, pay attention to the location the tube is placed

  • Apical (top) or Basilar (base)
  • Apical chest tube removes Air
  • Basilar chest tube removes

Blood or fluid (due to gravity)

Examples

  • An apical chest tube is draining 300 mL the first hour is bad … Bubbling (air) is expected
  • A basilar chest tube is draining 200 mL the first hour is expected
  • An apical chest tube is not bubbling … This is a bad sign because bubbling (air) is expected
  • A basilar chest tube is not bubbling … This is a good sign because bubbling (air) is not expected

Example

Pt presents with a unilateral hemopneumothorax. How to care for this pt?

  • Place an apical chest tube for the pneumothorax and a basilar for the hemothorax

Bilateral pneumothorax needs apical chest tube one on the right and one on the left

  • Air tube = Apical = Top, on both sides

Posttrauma or postsurgical pt needs

  • Pt presents with a unilateral hemopneumothorax. How to care for this pt? … Place an apical and a basilar chest tube on the side of the problem … Always assume trauma and surgery is unilateral unless otherwise specified

Trick question

Were would you place a chest tube for a postop right pneumonectomy?

  • Postop right pneumonectomy does not need a chest tube … Since the right lung was removed, there is no need for a chest tube
  • Chest tube will however be used for lobectomy (removal of a lobe of the lung), or wedge resection

Closed chest drainage devices

Knock someone or something over: to push or strike someone or something, causing the person or the thing to fall

  • Types: Jackson-Pratt, Emisson, pneumovac, hemovac, etc.
  • What happens if one of those drainage devices is knocked over?
    • Ask pt to take a deep breath and set the device back up
    • Not a medical emergency … No need to call the physician

If the water seal of the chest tube breaks

  • Clamp
    • Clamping, unclamping, and placing the tube under water must be done in 15 seconds or less
  • Cut the tube away
  • Submerge (stick) the end of the tube under sterile water

The most important step

  • Unclamp the tube if it was initially clamped, (clamping the tube prevent air to get into the chest but does not allow anything from the chest to get out)

Note

If for whatever reason the chest tube breaks, clamp, unclamping to placing the tube under water must be done in 15 seconds or less

Question

The water seal chamber of the chest tube in a pt with a pneumothorax/hemothorax breaks. What is the first course of action for the nurse?

  1. Clamp the tube
  2. Cut the tube away
  3. Submerge (or stick) the end of the tube under sterile water
  4. Unclamp the tube if it was initially clamped

In this case, the first course of action is the clamp the tube

Question

The water seal chamber of the chest tube in a pt with a pneumothorax/hemothorax breaks. What is the priority (best) action of the nurse?

  1. Clamp the tube
  2. Cut the tube away
  3. Submerge (or stick) the end of the tube under sterile water
  4. Unclamp the tube if it was initially clamped

In this question, the priory action for the nurse is to submerge the end of the tube under sterile water because doing so prevents air from getting into the chest. At the same time, this allows air or blood from the chest to get out

  • This solves the problem by reestablishing the water seal

Note

Clamping, unclamping, and placing the tube under water must be done in 15 seconds or less

Question

You notice on the monitor that a pt has v-fib. Pt is unresponsive and there is no pulse. What is the first step in the management of this pt?

  1. Place a backboard under pt’s back while pt is supine
  2. Start chest compression

The first step is to place the backboard under pt’s back. “First” is about order.

Question

You notice on the monitor that a pt has v-fib. Pt is unresponsive and there is no pulse. What is the best step in the management of this pt?

  1. Place a backboard under pt’s back while pt is supine
  2. Start chest compression

“Best” is about what is the priority. Chest compression is the priority action.

If a chest tube gets pulled out …

  1. Take a gloved hand and cover the opening (first step)
  2. Take a sterile Vaseline gauze and tape 3 sides (best step)

Chest tube is bubbling … Ask (1) where it is bubbling, and (2) when it is bubbling? Ask the following 2 questions

  • Bubbling … Where? In the water seal chamber
    • If it is intermittent, it is good (document it)
    • If it is continuous, it is bad and indicates a break/leak in the system (find it and tape it)
  • Bubbling … Where? In the suction control chamber
    • If it is intermittent, suction pressure is too low (increase it at the wall until it is continuous)
    • If it is continuous, it is good (document it)

Analogies

  • A straight catheter is to a Foley catheter, as a thoracentesis is to a chest tube
    • A straight catheter goes in and out … A Foley goes in, secure it, and continuous drainage
    • Thoracocentesis = go in and out … Chest tubes = go in, secure it, and leave it in place
  • A Foley has a higher risk of infection than a straight cath
  • A chest tube has a higher risk of infection than thoracocentesis

Rules for clamping tubes

  • Do not clamp a tube for more than 15 seconds without a physician’s order
  • Use rubber tooth (will not puncture tubing), double clamps
  • Therefore, when the water seal breaks, the nurse has no more than 15 seconds to clamp, cut the tube, submerge it under sterile water, and then unclamp it

Congenital Heart Defects

  • It’s either they cause a lot of trouble or no trouble
    • But nothing in between
  • Memorize one word: “TRouBLe” with the lower case vowels because congenital heart defects are either:
    • “TRouBLe” or
    • Nothing to worry about

A pediatric pt with “TRouBLe” as congenital heart defect

  • Needs surgery now/soon to live
  • Has slowed/delayed growth and development (failure to thrive)
  • Has a shortened life expectancy
  • Parents will experience a lot of grief, financial and emotional stress
  • Pt is likely to be discharge home on a cardiac monitor
  • After, birth, pt will be in the hospital for weeks
  • Pediatrician or pediatric nurse will likely refer pt to a pediatric cardiologist

Question

The nurse is teaching the parent of an infant born with Tetralogy of Fallot. Which of the following should the nurse talked to the parents about in the teaching session?

  • The nurse should teach the newborn’s parents all of the choices listed above

A “TRouBLe” congenital heart defect

  • “TRouBLe” shunts blood Right to Left
  • “TRouBLe” is Blue (cyanotic)
  • All “TRouBLe” start with the letter “T”
    • Tetralogy of Fallot
    • Truncus arteriosus
    • Transposition of the great vessels
    • Tricuspid atresia
    • Totally anomalous of pulmonary vasculature (TAPV)

Except, Left ventricular hypoplastic syndrome

These are examples if No TRouBLe congenital heart defects

  • Ventricular septal defect (VSD)
  • Patent ductust arteriosus (PDA)
  • Patent foramen ovale
  • Atrial septal defect
  • Pulmonic stenosis

All children with a congenital heart defect, whether TRouBle defect or No TRouBle defect, have

  • A Murmur
  • An echocardiogram need to be done to find out the cause of the murmur

4 defects of Tetralogy of Fallot — “PROVe”

  • Pulmonary artery stenosis
  • RVH (right ventricular hypertrophy)
  • Overriding aorta
  • VSD (ventricular septal defect)
  • No need to know what they are … Just need to spot them as answer choices on the board

Infectious Disease and Transmission-Based Precautions

There are 4 transmission-based precautions

  • Standard or universal
  • Contact
  • Droplet
  • Airborne precaution

Contact precautions

  • Anything enteric (GI, or fecal/oral)
    • C. diff., Hepatitis A, E. coli, cholera, dysentery

Staph

  • RSV (droplets fall onto object then pt touches object or put it in mouth)

Do not cohort 2 RSV pts unless culture and symptoms say that have the same disease

Herpes

PPE (personal protective equipment) for contact precaution

  • Private room is preferred
  • Can be in the same room if cohort based on culture and not symptoms
  • Hand washing  Gown  Gloves
  • Disposable supply (gloves, paper plates, plastic utensils)
  • Dedicated equipment (stethoscope, BP cuff) and toys stay in the room

Droplet precautions

  • For bugs travelling on large particles through Coughing, Sneezing to less than 3 feet
  • Meningitis
  • H. influenza b
    • Example: epiglottitis (nothing in the throat)

PPE (Personal Protective Equipment)

  • Private room is preferred
  • Can be in the same room if cohort based on culture and symptoms
  • Hand washing  Mask  Goggle or Face shield  Gloves
  • Disposable supply
  • Dedicated equipment

Airborne precautions “Air MTV”

  • MMR
  • TB
  • Varicella (chickenpox)

PPE

  • Private room is preferred
  • Can be in the same room if cohort based on culture and symptoms
  • Hand washing  Goggle or Face shield  Gloves
  • Wear mask when living the room
  • Keep door closed
  • Disposable supply (not essential)
  • Dedicated equipment (not essential)
  • Negative airflow

PPE (Personal Protective Equipment)

  • Order to put in on … The “Gs” are in reverse alphabetical order and “Mask” comes 2nd
    • Gown
    • Mask
    • Goggle
    • Gloves
  • Order to take it off … Do so in alphabetical order
    • Gloves
    • Goggle
    • Gown
    • Mask

Math Problems

Dosage calculation

IV drip rates = Volume × Drop factor / Time

  • Micro/Mini drip = 60 drops per mL
  • Macro drip = 10 drops per mL Pediatric dose (2.2 lbs = 1 kg)

Lecture 4 • Mark Klimek • 96:58

Crutches, Canes, Walkers

One of the major human functions is locomotion. Therefore, crutches, canes and walkers are tested on the NCLEX exam even though they are not really emphasized in school. Also, such knowledge is good for patient teaching. With that said, crutches, canes and walkers are devices used to help pts with an unstable gait, whose muscles are weak or who require a reduction in the load on weight- bearing structures

How do you measure the length of crutches?

  • Measuring crutches is important for risk reduction when ambulating and to avoid nerve problems
  • The length of a crutch is measured by
    • Holding it vertically and placing the tip on the ground
    • Having 2 to 3 finger widths between the pad and the

anterior axillary fold

    • The tip is located to a point lateral (6 inches) and slightly in front of foot (6 inches)

Rule out landmarks on foot or say axilla!

  • Handgrip measurement
    • The angle of elbow flexion is 30 degrees
    • The wrists should be at the level of the handgrip

How to Teach Crutch Gaits?

  1. point gait—move a crutch and opposite foot together, then the other crutch with other foot together

    • Together (Right leg & Left crutch)

 Together (Left leg & Right crutch)

    • For mild bilateral leg weaknesses
  1. point gait—move (2 crutches & bad leg) together  Followed by unaffected leg

    • The gait goes 3-1, 3-1, 3-1
    • The affected (bad) leg is not on the ground
    • The unaffected (good) leg is on the ground
  1. point gait—move everything separately
    • Move crutch  Move opposite foot  Followed by other crutch  Followed by opposite foot
    • Right crutch  Left foot  Left crutch  Right foot
    • 4-point gait is very slow but very stable

Swing-through is for non-weight bearing (amputees)

    • Similar to 3-point gait
    • The unaffected foot get pass the tip of both crutches
    • The person may be an amputee or does not bear weight on the leg at all
    • Can move really fast

When do you use these gaits?

    • Use Even-point gait for even, odd-point gait for odd
    • Use the even numbered gaits when weakness in the feet is evenly distributed
      • 2-point for mild problems
      • 4-point for severe
    • Use the odd numbered gait when one leg is affected
      • 3-point for one leg
    • If pt cannot bear weight or amputation
      • Swing-through

Example

A pt affected with early stages of rheumatoid arthritis. What gait should the pt use?

    • Both legs affected (because it is a systemic disease)
    • Early stage—mild
    • 2-point gait

Example

A pt has left ATK (above the knee) amputation 2 days ago. What gait should the pt use?

    • Non-weight bearing
    • Swing-through

Example

Pt is first day postop, right knee, partial weight bearing allowed. What gait should the pt use?

    • One leg affected
    • Odd-numbered gait
    • 3-point gait

Example

Pt is in advanced stages of ALS. What gait should the pt use?

    • Bilateral leg weakness (because it is a systemic disease)
    • Even-numbered gait
    • Advanced stages = Severe
    • 4-point gait

Example

Pt with left hip replacement, 2nd day postop on non-weight bearing instruction. What gait should the pt use?

    • Non-weight bearing of 1 leg
    • Swing-through gait

Example

Pt with bilateral (B/L) total knee replacement first day postop. Weight bearing is allowed. What gait should the pt use?

    • Even-numbered gait = Bilateral
    • Weight bearing
    • First day postop = Severe
    • 4-point gait

Example

Pt with bilateral total knee replacement 3 weeks postop. What gait should the pt use?

    • Even-numbered gait = Bilateral
    • Weight bearing
    • 3 weeks postop = mild
    • 2-point

Going Up and Down the Stairs With Crutches

    • Remember this phrase
      • “Up with the Good, and Down with the Bad”
      • When you go up the stairs, the good foot move up first
      • When you go down the stairs, the bad foot move down last
    • But, no matter what
      • Both crutches always move with the bad leg

Figure 2. Crutcher.

Figure 3. Cane.

Figure 4. Walker.

Cane

    • Hold cane on the unaffected (strong) side
    • Advance cane with the opposite side for a wide base of support
    • Handgrip should be at the level the wrist

Walker

    • Correct way to use a walker
      • The walker is on the side of the pt, the pt “Picks it up … Sets it down … Walks to it”
      • Once the walker is in front of the pt, the pt “Holds on to chair, Stands up, Then grabs walker”
    • Don’t tie belongings to the front of the walker—Tie them to either side so it won’t tip over
    • The NCLEX board does not like tennis balls or wheels on walker can create problem

Psychiatry

First thing to ask in a psych question is: “Is the pt psychotic or non-psychotic?”

    • The answer to this question will determine care plan, treatment, length of stay, legality, etc.

A Non-psychotic person has insight and is reality based. What kinds of answers do you pick for these people? What techniques do you use?

    • Good therapeutic communication … Looks like a Med/Surge pt
    • Examples of therapeutic communications
      • That must be very difficult/overwhelming for you
      • How are you feeling?
      • Tell me more about your …
      • The exam is looking for “reflection, clarification, amplification, restatement, etc.”

The Psychotic person has no insight and is not reality based

    • They don’t think they’re sick—everyone else has the problem
      • Examples are: delusions, hallucinations, illusions

Delusions, hallucination and illusion are psychotic symptoms

    • Delusions—a false, fixed belief or idea or thought. There is no sensory component. It is all in your head. It is just a thought … 3 types of delusion
      • Paranoid—People are out to get/kill me
      • Grandiose—“I’m Christ” … “I am the President” … “I am the world’s smartest person”
      • Somatic—Body part (I have x-ray vision, there are worms inside my arm)
    • Hallucination—a sensory experience
      • Auditory (1st m c)—voices telling you to harm yourself
      • Visual (2nd m c)—I see bugs on the wall
      • Tactile (3rd m c)—I feel bugs on my arm (Most common = m c)
      • Gustatory (taste)
      • Olfactory (smell)
    • Illusion—a misinterpretation of reality. It is sensory

Differentiation between hallucination and illusion

    • With illusion there is a referent in reality
      • A referent is something that both the clinician and the pt can refer to … There is actually something there
      • The cord is a snake
    • With hallucination, there is nothing there

Example

The pt staring at the empty wall says, “Listen, I hear demon voices.” Is that statement from the pt a hallucination and an illusion?

    • There is no referent there
    • This is a hallucination

Example

The same pt overhears nurses and doctors laughing and talking at the nursing station, and says, “I hear demon voices.” Is that statement from the pt a hallucination and an illusion?

    • There is actually a referent (real people) there
    • This is an illusion

Other examples

    • A pt looks with a blank stare and says, “I see a bomb.”
      • This is a hallucination
    • A pt looking at the fire extinguisher on the wall and says look, “I see a bomb.”
      • This is an illusion

How do you deal with these psychotic patients?

    • To deal with these psychotic pt, the first thing to ask is what type of psychosis the pt has?

There are 3 types of psychosis

  1. Functional psychosis
  2. Psychosis of dementia
  3. Psychosis of delirium
  4. Functional psychosis—they can function in everyday life
  • 90% of the followings make up this category
  • Chemical imbalance in the brain
  • They are “Skeezo, Skeezo, Major, Manics”

o Schizophrenia, Schizoaffective disorder, Major depression (not depression), Mania

Example

  • Bipolar = Depression and Mania
  • Bipolar pts are psychotic in acute mania
  1. Psychosis of dementia—what is their problem?
  • Actual Brain destruction/damage
    • Due to Alzheimer, stroke, organic brain syndrome
    • Anything that says Senile/Dementia falls in the category
  1. Psychotic Delirium—temporary, sudden, dramatic, episodic secondary to something else
  • Loss of reality
    • Due to UTI, thyroid imbalance, adrenal crisis, electrolytes, medications/drugs

Recap

Approach to Answering Psychiatric Questions

  • First thing to ask is
    • Is the pt non-psychotic? Or, is the pt psychotic?
  • Pt is non-psychotic
    • Address pt as you would address any Med/Surg pts Use therapeutic communication
  • Pt is psychotic
    • Next, ask if they are functional, demented, or delirious?

Functional = (1) Acknowledge feeling, (2) Present reality, (3) Set limits, and (4) Enforce these limits

Demented = (1) Acknowledge their feeling, and (2) Redirect them—give them something they can do

Delirious = (1) Acknowledge feeling, (2) Reassurance about safety and temporariness of their condition

Functional Psychosis

  • Schizo, mood disorders thought process, and mania (chemicals out of whack)
  • This pt has the potential to learn reality (no brain damage)
  • Your role as a nurse—teach reality
  • Use the 4 step process to teach reality
    • (1) Acknowledge feeling, (2) Present reality, (3) Set limits, and (4) Enforce these limits

What does this look like in a question?

    1. The answer acknowledges pt’s feeling (look for the word “feel”)

You seem upset … That is so sad … It’s been so difficult … Tell me more about how you’re feeling

    1. Now, present reality … “I know you see that demon, but I don’t see a demon” … Or, “I am a nurse, this is hospital, this is your breakfast”
    2. Set limit. ”We are not going to address that. Stop talking about…”
    3. Enforce limit. “I see you’re too ill, so our conversation is over.” Ends the conversation. You’re not punishing the client by taking away privileges

Psychosis of dementia

  • They cannot learn reality … Don’t present it! They can’t learn it! Thus frustrates them, and may discourage you!
  • Deal with their problems in 2 steps
    • (1) Acknowledge their feeling, and (2) Redirect them—give them something they can do

Do not confuse not presenting reality with reality orientation (Person, place, and time)

  • Reality orientation = Pt is oriented to person, place, and time

Example

  • Alzheimer lady is the lobby of waiting area of her nursing home. It is Sunday and she is all dressed up. You day to her, “Mrs. Smith, you are all dressed up.” She said, “Yeah! My husband is going to pick me up. We are going to church.” The problem is that the husband has been dead for 10 years.
    • She has a false, fixed belief
    • She is delusional (or she is psychotic)
    • What do you say to her?
    • First, acknowledge her … You say, “That sounds nice.” (acknowledging)
    • Second, redirect her … You say, “Why don’t we sit down here and talk about church? … What church do you go to?” (redirecting)
    • Don’t tell her husband is dead!, which is presenting reality

Psychosis of delirium

  • This is temporary, sudden, dramatic, episodic, secondary loss to reality
  • Usually due to some chemical imbalance in the body
  • Causes—UTI, thyroid imbalance, adrenal crisis, electrolytes, medications/drugs
  • To manage these pts, treat the underlying cause
    • Acknowledge feeling
    • Reassure them of safety and temporariness of their condition
  • They lost touch with of reality—Redirect them is futile

Example

A pt with schizoaffective disorder who points to 2 people talking across the room. The pt says, “Those people are plotting to kill me.” What would you say? What is the most important word in the vignette?

  • Schizoaffective—psychosis
  • I can see that would be frightening. They are not plotting.
  • We are not going to talk about that. I can see you are too ill. We are ending the conversation

Example

A pt with Alzheimer disease who during your conversation points to 2 people talking across the room and says, “You see these people, they are plotting to kill me”

  • Alzheimer Disease—category is dementia
  • Acknowledge feeling—“I understand you seem to be scared”
  • Redirect—Let’s go somewhere you feel safe

Example

A pt with delirium tremens who during your conversation points to 2 people talking across the room and says, “You see these people, they are plotting to kill me”

Delirium tremens …

  • “That must be scary”
  • But you are safe. Your fear will go away when you get better

Psychotic symptoms

Loose associations

  • Flight of Ideas: Rapid flow of though
  • Word Salad: Throw words together and toss out … (Sicker than flight of ideas)
  • Neologisms: Make it up
  • Narrowed self-concept: When a psychotic refuse to change their clothes or leave the room. Leave them alone
    • This is a functional psychosis

“Don’t make a psychotic do something they don’t want to do”

  • Idea of reference: You think everyone is talking about you

Dementia hallmark: Memory loss, inability to learn

  • Always acknowledge feeling
  • 2nd step always begins with “Re” … Reassure, Redirect, Reality

Recap

Approach to Answering Psychiatric Questions

  • First thing to ask is
    • Is the pt non-psychotic? Or, is the pt psychotic?
  • Pt is non-psychotic
    • Address pt as you would address any Med/Surg pts Use therapeutic communication
  • Pt is psychotic
    • Next, ask if they are functional, demented, or delirious?

Functional = (1) Acknowledge feeling, (2) Present reality, (3) Set limits, and (4) Enforce these limits

Demented = (1) Acknowledge their feeling, and (2) Redirect them—give them something they can do

Delirious = (1) Acknowledge feeling, (2) Reassurance about safety and temporariness

of their condition

Lecture 5 • Mark Klimek • 71:46

Diabetes Mellitus (DM), Diabetes Insipidus (DI), Insulin

Diabetes mellitus = An error in glucose metabolism … Glucose is the body’s primary fuel source

  • Can be a lack of insulin DM1
  • Can be insulin resistance DM2

DIABETES INSIPIDUS = Not a type of DM! … It is insidious, diabetes w/out the glucose element

  • It is Polyuria, Polydipsia leading to dehydration, due to low ADH.
  • It is just the fluid part

So question is about low urine output or high urine output? …

  • Similar to DM, DI has a high urine output

What is the opposite of Diabetes Insipidus?

  • It is SIADH = Syndrome of inappropriate ADH (antidiuretic hormone)

So, DM has polyuria, polydipsia Therefore, DI also has polyuria, polydipsia

However, SIADH is the opposite of the above 2 conditions …

  • It presents w/ oliguria and no thirst
  • Decrease urine output
  • And then, decrease serum specific gravity (due to retention of water)
  • Increase urine specific gravity (due to decrease urine volume)

Lots of urine retained, specific gravity is low = SIADH Fluid Volume Deficit = DM, DI

Nursing Diagnosis?

Fluid Volume Excess = SIADH

Diabetes

  • Type I—Insulin dependent, Juvenile onset, Ketosis prone
  • Type II—Non-insulin dependent, Adult onset, Non-ketosis prone
  • S/Sx of DM
    • Polyuria—pee a lot
    • Polydipsia—thirsty
    • Polyphagia—(eat/swallow a lot)

Treatment for DM Type I (if you don’t treat)

  • They will “DIE”
  • Diet (calories from carbs, least important)
  • Insulin (most important)
  • Exercise

Treatment for Type II DM

  • They are “DOA”
  • Diet (most important)
  • Oral hypoglycemic
  • Activity

Diet for DM2

  • Primary treatment modality is Calorie restriction
  • 1200 Cal, 1400 Cal, 1600 Cal
  • These pts need to eat 6 small feeding per day—smaller more frequent meals—keeps blood sugar more stable

Question

What is the best dietary action a DM2 should take?

      1. Restrict calories
      2. Divide meal into 6 feedings a day

Answer: (a) because pt can eat 6 meals but does not limit the Cal with each meal Insulin acts to lower blood sugar

4 types of Insulin are covered here

R-Regular insulin—clear solution, IV drip (HESI-intermediate, Rapid, Run IV)

    • Onset: 1 hour
    • Peak: 2 hours
    • Duration: 4 hours … (Audio says 3 hours, but it is 4 hours)
    • Pattern: 1-2-4 (Pay attention to peak)

N-NPH, Intermediate insulin—it is cloudy, N = Not So Clear, Fast (Cloudy = Suspension—it precipitates—can’t give IV drip), N = not so fast, not in the bag

    • Onset: 6 hours
    • Peak: 8 to 10 hours
    • Duration: 12 hours
    • Pattern: 6-8-10-12 (Hear the even #s and pay attention to peak)

Clear = Solution

Cloudy = Suspension  Will precipitate (Not given over IV drip or put in an IV bag)

Question

How would the board ask question about peak of insulin?

For instance, you give 30 units of insulin to a pt at 7 a.m. When do you check for hypoglycemia?

    • Answer = Add the insulin peak time to the time of insulin administration
    • For instance, if the pt was given NPH at 7 a.m., add 8 to 10 hours to the time
    • Answer = Check for hypoglycemia between 3 and 5 p.m.

Lispro: (Humalog)

    • Don’t give it AC (before meal) … Give it with the meal
    • Onset: 15 min
    • Peak: 30 min
    • Duration: 3 hrs
    • Pattern: 15-30-3

Glargine (Lantus)

    • Long-acting insulin
    • No Peak
    • Duration 12 to 24 hrs
    • Little to no risk for hypoglycemia (only one you can safely give at bedtime)

Note: Always check insulin expiration date What action invalidates the manufacturers date?

    • Opening the package
    • Once the package is open, the new expiration date is 30 days after that
    • Open package without an opening or expiration date should be thrown out
    • Label the package either with
      • “OPEN” and date package is open or
      • “EXP” and expiration date
    • Once the package is open, refrigeration is optional
      • However, unopened bottle must be kept refrigerated
      • Although it is good practice to teach pt to refrigerate insulin at home

Exercise potentiates insulin action

    • Exercise is like another shot of insulin
    • Therefore, if a student is schedule to play soccer (exercise) this afternoon … It is necessary to decrease the dosage of insulin
    • In addition, the school nurse must give the student rapidly metabolized carbohydrates— snacks or juice

Sick Days … Pt has a fever or the flu, and so on

    • Serum glucose levels go up
    • Need their insulin even though pt is eating
    • Take sips of water because they get dehydrated
    • Any sick diabetic pt has 2 problems
      • Hyperglycemia and Dehydration

Acute complications of Diabetes

    • Low blood glucose—a.k.a. Hypoglycemia or Hypoglycemic shock or Insulin shock/reaction
    • Why are some of the causes
      • Not enough food
      • Too much insulin (#1 cause, can lead to permanent brain damage)
      • Too much exercise

What does hypoglycemia look like?

    • Think of Drunk pt in Shock
    • Drunk
      • Staggering gait
      • Slurred speech
      • Cerebral impairment (labile)
      • Slow reaction time
      • Decrease social inhibition
    • Shock—Vasomotor collapse
      • Tachycardia, tachypnea, Low BP
      • Cold/clammy, mottled skin

Treatment

    • Give pt sugars or Rapidly metabolizable carbohydrate such as
      • Juice (any), candy, regular soda, milk (lactose), honey, icing, jelly, jam
    • Boards want sugar + starch or protein
      • For example, apple juice + turkey, Milk is sugar/protein—1/2 cup Skim milk
    • Bad answer
      • Candy + Soda—1 sugar is good, 2 sugars are bad
      • 5 packs of sugar emptied into a glass of orange juice
    • Unconscious pts—pay attention to location
    • Glucagon IM if the mother is on the phone
    • Dextrose IV (D10, D50) if in the ER

DKA—High Glucose in a Type I (keto is the clue!)

Causes

    • Too much food
    • Not enough insulin
    • Not enough exercise

#1 cause acute viral Upper Respiratory Infection within last 2 weeks

S/Sx of DKA is “DKA”

    • Dehydration (dry, poor skin elasticity and turgor, warm) … Water is a coolant (you overheat)
    • Ketones in serum, Kussmauls, High K+
    • Acidosis, Acetone breath, Anorexia due to nausea

Note: Ketone in urine does not necessarily means DKA

Treatment

    • Insulin IV (Regular!)
    • IV fluid! 200 mL/hr (some of the fastest rate)

HHNK or HHS or HHNS

    • High blood sugar in a Type 2
    • These pts don’t burn ketones, no acid
    • Whenever you see HHNK, think dehydration
    • Severe Dehydration!
      • Skin is dry, flushed, decreased turgor, increased HR
      • #1 Nursing diagnosis: fluid volume deficit (same as dehydration)
      • #1 Nursing intervention: Rehydration!
      • Outcomes in successful treatment: Increase urine output, Moist mucous membrane, etc.
      • Long-term complications: Poor perfusion, Peripheral neuropathy

Between DKA and HHNK

    • Which one is more dependent on insulin?
      • DKA pt is more dependent on insulin
      • HHNK pt needs to be rehydrated
    • Which one has a higher mortality rate?
      • More pts die HHNK
    • Which is a higher priority?
      • DKA is a more acute condition and responds very quickly to insulin
      • HHN pts show up late in the emergency room and do not readily respond to treatment

Long-term complication of diabetes

    • Related to
      • Poor tissue perfusion or
      • Peripheral neuropathy
    • Examples of long-term complications: Renal failure, Gangrene, Heart failure, Urinary incontinence, Pt can’t feel a burn on the foot
    • For instance
      • Renal failure is a cause of poor perfusion
      • Urinary incontinence is a cause of peripheral neuropathy

Which lab test is the best indicator of long-term blood glucose level?

    • Hb A1C, a.k.a. glycosated Hb or glycosylated Hb
      • Average blood sugar over last 90 days
    • (Hb = Hemoglobin)
    • Hb < 6 is normal
    • Hb > 8 is out of control
    • Hb 7 Borderline—have pt come in for evaluation

Lecture 6 • Mark Klimek • 87:50

Drug Toxicities, Hiatal hernia, Dumping syndrome Drug Toxicities—Know these FIVE medications

  1. Lithium (antimania drug)
    • Used for Bipolar
      • Specifically, for the manic episodes but not for the depression
    • Therapeutic level: 0.6 to 1.2
    • Toxic level: >2.0
    • Notice gray area: 1.3 to 2

Lanoxin or Digoxin

    • Used to treat A-Fib and CHF
    • Therapeutic level: 1 to 2
    • Toxic level: >2

  1. Aminophylline—muscle spasm relaxer for the airway
    • Compound of the bronchodilator theophylline
    • Therapeutic level: 10 to 20
    • Toxic level: >20
    • Non-therapeutic level: <10 … if it is not therapeutic, increase dose of medication, and assess for compliance

Dilantin (phenytoin)

    • Seizure medication
    • Therapeutic level: 10-20
    • Toxic level: >20

Bilirubin

    • Breakdown product of Red Blood Cells
    • Normal level in adults: 0.2 to 1.2
    • Always tested in the Newborns on the NCLEX
    • In Newborns bilirubin is much higher than in adults
      • Elevated level: 10 to 20
      • Toxicity: >20
    • When do physicians want to hospitalize these newborns?
      • When bilirubin level is about 14 to 15

Patterns

    • 1s and 10s
    • 2s and 20s
      • 2s: Low # (Lithium and Lanoxin)
      • 20s: High # (Aminophylline, Dilantin and Bilirubin)

Jaundice—Yellow skin from excess bilirubin in the blood

    • It appears as yellow skin and sclera

Kernicterus—Excess bilirubin in the brain

    • Occurs when level in the blood gets >20
    • In the brain, it may cause aseptic (sterile) meningitis or encephalopathy (don’t need to know)
    • It can be DEADLY

Opisthotonos

    • Position the newborn assume due to irritation of the meninges from kernicterus
    • Presentation: hyperextended posture … (Is a medical emergency)

Question

In what position do you place an opisthotonic newborn?

    • Put newborn on the side

Pathological vs. Physiological Jaundice

    • If the newborn comes out yellow, something is wrong = Pathologic jaundice
    • If the newborn turn yellow 2 to 3 days postpartum, that’s ok = Physiologic jaundice

Dumping Syndrome vs. Hiatal Hernia

    • Both gastric emptying problems and are opposites

Hiatal Hernia

    • Regurgitation of gastric acid upward or backward into esophagus
    • “Like a cow with 2 stomachs,” gastric contents go in wrong direction at the correct rate
    • S/Sx of hiatal hernia is similar to GERD (Heartburn and indigestion)
    • S/Sx of hiatal hernia = S/Sx of GERD when lying down after a meal
      • In other words, Heartburn, Indigestion on lying down after eating

Treatment

      • Can do 3 things, as shown below
  1. Elevate HOB (head of bed) during and 1 hour after meals
  2. Increase the amount of fluids with meals
  3. Increase the amount of Carb content
        • These cause the stomach to empty quickly so its content doesn’t back up
        • High-atal Hernia … Everything high

Dumping Syndrome

    • Gastric contents are dumped too quickly into duodenum
      • Right direction but at wrong rate
    • S/Sx of dumping syndrome
      • Drunk: Staggering gate, impaired judgment, labile—all blood gone to gut
      • Also get Shock: cold/clammy, tachycardia, pale
      • Now add Acute abdominal distress: n/v, diarrhea, cramping, guarding, borborygmi, bloating, distention
    • Dumping syndrome = Drunk, Shock, Acute Abdominal Distress

Note

    • Drunk is what it is
    • Shock is what it is
    • Drunk + Shock = Hypoglycemia
    • Drunk + Shock + Acute abdominal distress = Dumping syndrome

Treatment of Dumping Syndrome

    • Can do 3 things, as shown below
  1. Lower HOB (head of bed) during meals and turn pt on the side
  2. Decrease the amount of fluids 1 or 2 hours before or after meals
  3. Decrease the amount of Carb content
      • These 3 things prevent the stomach to empty quickly or dump its content into the duodenum
    • Dumping syndrome … Everything low

What is protein is added in the diet?

    • Protein does the opposite of carbohydrate
    • Protein bulks gastric content, takes longer to digest, and moves slower through the gut
    • Therefore, give
      • Low protein in hiatal hernia
      • High protein for dumping syndrome

Electrolytes

    • Memorize these 3 sentences
  1. Kalemias do the same as the prefix (hypo-, hyper-), except for HR and urine output which go opposite
  2. Calcemias do the opposite as the prefix
  3. Magnesemias do the opposite as the prefix
    • Natremias
      • HypoNatremia = Volume overload … HyperNatremia = Dehydration

Kalemia(s)

    • Go in the same direction as the prefix, except for HR and urine output (UO), which go in the opposite direction
    • Hypo—Symptoms go low with hypo, except HR and UO
    • Hyper—Symptoms go high with hyper, except HR and UO

Some S/Sx of Hyperkalemia

    • Brain: seizures, agitation, irritability, loud down
    • Heart: tented T waves, ST elevated, tachypnea
    • Bowel: diarrhea, borborygmi
    • Muscle: spasticity, increase tone, hyperreflexia (3+, 4+)
    • Heart rate: down (bradycardia)
    • UO: down (oligouria)

Some S/Sx of Hypokalemia

    • Lethargy, bradypnea, paralytic ileus, constipation, muscle flaccidity, hyporeflexia (0, 1+)
    • Tachycardia (HR is up)
    • Polyuria (UO is up)

Question

Your patient has hyperkalemia, select all that apply

  1. Adynamic ileus
  2. Obtunded
  3. 1+ reflex
  4. Clonus (irritable)
  5. U wave
  6. Depressed ST
  7. Polyuria
  8. Bradycardia

Answer

    • Kalemia goes in the same direction, except HR and urine output … therefore,
    • Clonus are bradycardia are right

Calcemia(s)

    • Go in the opposite direction as the prefix
    • Hypo—Symptoms go high with hypo
    • Hyper—Symptoms go low with hyper

Calcemias do the opposite of the prefix—it is a sedative

    • So Hypercalcemia is bradycardia, bradypnea, flaccid, hypoactive reflexes, lethargy, constipation, etc.
    • So Hypocalcemia is agitation, irritability, 3+ or 4+ reflexes, spasm, seizure, tachycardia, Chvostek sign (tap the cheek), Trousseau (inflate BP cuff), etc.

Choosing answers for potassium and calcium

    • For potassium pick answers related to heart problems
    • For calcium pick answers related to muscle problems

Magnesemia(s)

    • Magnesium goes in the opposite direction of the prefix—it is also a sedative

It is possible that S/Sx are from several electrolytes imbalances. In that case,

    • Choose CALCIUM if nerve or skeletal involvement
    • Pick POTASSIUM for any other symptom
      • Generally anything effecting blood pressure

Your patient has diarrhea … Which one of the following electrolyte imbalances causes diarrhea?

Hyperkalemia, hypokalemia, hypocalcemia, or hypomagnesemia

    • Tetany? Hypocalcemia

Test tip

    • Common mistake
    • Tetany = Hyperkalemia—prefix example. Pay attention

Natremia(s)—Sodium

    • HypErnatrema = DEhydration
      • Hot, flushed, dry skin, thready pulse, rapid HR … Give fluid
      • Associate “E” in hypernatremia with DEhydration
    • HypOnatremia = Overload
      • Crackles, distended neck veins … Fluid restriction, Lasix
      • Associate “O” in hyponatremia with Overload
      • Nursing Dx: Fluid Volume Excess

Question

In addition to a high potassium, what other electrolyte abnormality can be seen in DKA?

    • Hypernatremia = Dehydration
    • DKA should make you think of DEhydration, which is also associates with hypErnatremia

Question

In addition to High Potassium what other electrolyte imbalance is possible in DKA?

    • Answer: Hypernatremia

Review—Think dehydration or Fluid overload

    • SIADH: Hyponatremia
    • DI: Hypernatremia
    • HHNK: Hypernatremia

How to spot early signs of electrolyte imbalance?

    • The earliest sign of any electrolyte disturbance is
      • Numbness and tingling = Paresthesia
      • Circumoral paresthesia = Numbness and tingling around the lips

The universal sign of all electrolyte imbalances is

      • Muscle weakness = Paresis

Treatment

    • Potassium is the only one Boards will test

Never Push Potassium IV

    • Potassium <40 mEq/L of IV fluid
      • If >40 mEq/L, clarify dosage with physician

How do you lower potassium?

    • Of all electrolyte imbalance, high potassium is the most problematic
    • High potassium can stop the heart
    • The fastest way to lower potassium level is to
      • Give D5W and regular insulin to decrease potassium
      • This will drive the potassium into the cell and out of the blood
      • Temporary solution but quick
    • Kayexalate is long-term solution
      • Through enema or ingestion, Kayexalate exchanges potassium for sodium
      • Potassium is eliminated through feces and pt becomes hypernatremic
      • Hypernatremia is managed with IV fluid administration
      • The downside is it takes hours to work
    • To solve this problem
      • Give D5W, Regular insulin, and Kayexalate and the same time D5W and Regular insulin work instantly

Kayexalate works in a few hours—K Exits Late

Lecture 7 • Mark Klimek • 115:33

Thyroid and Adrenals

Since the thyroid gland regulate metabolism, whenever you see the word “thyroid,” change it to

“metabolism”

Hyperthyroidism

    • Hypermetabolism

    • So, what are the S/Sx of hypermetabolism?
      • Weight loss
      • HR up, BP up
      • Hyperpersonality
      • They have heat intolerance … Can tolerate cold because body is like a furnace
      • Exophthalmos (bulging eyes) … Think Susan Sarandon, or Don Knotts

Exophthalmos is seen in Graves disease Run yourself into the Graves disease

Hyperthyroidism—3 Treatment Modalities

  1. Nuke it with radioactive iodine
    • Pt must flush three times after urinating
    • Call hazmat team if urine is spilled on the floor
    • Pt needs a private room in the first 24 hours
    • Visitors restriction and in hospital and at home in first 24 hours
  2. PTU (Propylthiouracil)

PTU “Puts Thyroid Under”

Figure 5. Don Knotts with Exophthalmos or bulging eyes.

    • PTU’s primary use is for cancer—Monitor WBC b/c pt is immunosuppress
  1. Thyroidectomy
    • Surgical removal of the thyroid is the

most common treatment

    • To answer questions on the Board correctly, pay attention whether it is a Total, Sub (a.k.a. Partial) thyroidectomy
    • Total thyroidectomy needs lifelong hormone replacement, and pt is risk for hypocalcemia due to difficulty to spare the parathyroid glands

Question

What are the symptoms of hypocalcemia?

    • Paresthesia, tetany, twitching, spasm, clonus, seizure, jitteriness, tremor (all UP!). also, Chvostek and Trousseau signs

Treatment of Subthyroidectomy

    • Do not need lifelong hormone replacement
    • May need to supplement at first
    • HOWEVER, they are at risk for thyroid storm

S/Sx of thyroid storm — A medical emergency

    • Temps of 105 or above
      • Get temp down, bring oxygen up
      • Bring body temperature down using ice packs/cooling blankets
      • Oxygen per mask at 10L
      • Stay with patient
    • High BP, stroke level — about 210/180
    • Severe tachycardia 180 as high as 200
    • Psychotically delirious

Lowering body temperature in thyroid storm

    • First step is ice pack
    • Best step is cooling blanket

Postop Risks in total thyroidectomy and subtotal thyroidectomy

    • First 12 hours—risks are the same for both total and subtotal
  1. Top priority is airway, due to edema
  2. Next is hemorrhage because it is an endocrine gland—very vascular
    • Next 12 to 48 hours—It matters what kind of surgery you’ve had now
  3. Total: big danger is tetany due to low calcium

TOTAL = TETANY … Can close off airway with an irreversible spasm

  1. Subtotal: big danger is thyroid storm

SUBTOTAL = STORM (Severe)

    • After 48 hours—risk is infection

Note: For any type of procedure, the risk of infection significantly increases after 72 hours

Hypothyroidism

    • Hypometabolism
    • So, what are the S/Sx of hypomatabolism?
      • Obesity
      • HR down, BP down
      • Personality: Flat, boring, dull
      • They have cold intolerance … Can tolerate heat
      • Academically challenged

Myxedema

    • This is when a pt with severe hypothyroidism presents with skin involvement

Myxedema coma

    • Severe hypothyroidism leading to decreased mental status, hypothermia, and other symptoms related to slowing of function in multiple organs
    • Medical emergency

Treatment of hypothyroidism

    • Levothyroxine (Synthroid)
    • Taken in the morning 30 minutes to 1 hour before breakfast
    • Taken alone on an empty stomach with water

Do not sedate these pts

    • They’re already super slow. They can go into a coma

Question

What pre-op order from the physician would you question?

    • Ambien (zolpidem) at hs
    • (at hs = at bedtime)

Question

A pt dx with hypothyroidism will be undergoing surgery the next morning. The physician ordered the pt NPO at 12:00 am. Pt is on Synthroid and multivitamin pills. What should the nurse question?

    • Clarify the NPO order for the Synthroid … Why?
      • The pt needs the Syntroid medication to get through surgery. Otherwise, the condition may potentiate the suppressing effects of the anesthesia during surgery
      • Therefore, don’t hold thyroid pills unless explicitly orders

Adrenal Cortex Disease

Interestingly, all adrenal cortex diseases either start with an “A” or a “C”

    • Addison Disease (a.k.a. hypoadrenalism or adrenal insufficiency), Cushing

Addison disease

    • Under secretion of steroids (they are a time bomb!)
    • S/Sx: pts are Hyperpigmented (very tan)
    • They do NOT adapt to stress

Question

What is the purpose of the stress response in an individual?

    • To maintain
      • A normal blood pressure to perfuse the brain and other organs
      • An adequate level of glucose to feed the body

Question

What could happen if these pts can’t adapt to stress?

    • Under stress, pts with Addisson disease will go into shock and have an hypoglycemic episode (Addisonian crisis)

Treatment

    • Give steroids
    • Glucocorticoids drugs that end in -SONE
      • Prednisone
      • Methylprednisone
    • “In Addison, you ADD-a-SONE”

Cushings Syndrome

    • If you have a cushy touchie … You got more
    • Oversecretion of adrenal cortex (steroids)

All the S/Sx of Cushings are the S/E of Steroid medications

    • Draw picture of a little man
    • Give man a MOON FACE
    • Give him a beard—hirsutism
    • Draw a big body—truncal or central obesity
    • Arms and legs are skinny—muscle atrophy
    • Bump on front—gynecomastia (big breast)
    • Bump on back—buffalo hump
    • Fill him full of water (he is retaining Na+ and water) He is losing K+ out the back
    • Give him some striae—stretch marks

Most important one of all—high serum glucose

      • Do Accu-Checks q6h. They look like diabetics
    • Easy bruising—put bruises all over him
    • Make him say something in a speech balloon … “I’M MAD, BECAUSE I HAVE AN INFECTION”
      • Grouchy (“Roid rage”)
      • Immunosuppressed

Figure 6. Cushings disease.

Important! … Draw this picture over and over, while repeating the list on the left such that to commit to memory the S/Sx of Cushings and the S/E of steroid medications

Question

A pt comes in with an acute exacerbation of COPD. The pt is being treated with Solu-Medrol (methylprednilosone) IV push q8 hours to reduce the inflammation in the airway. What nursing action needs to be taken while the pt is on the medication?

    • Do an Accu-Checks q6 hours
    • Since pt is on steroid, his condition is similar to diabetes even though he is not diabetics
    • The complications are worse if pt is diabetic

Treatment for Cushings

    • Adrenalectomy
    • What happens with a bilateral adrenalectomy?
      • Now pt has Addison disease
      • Now give steroids (ending in SONE) to treat.
      • Pt will start looking like Cushman (Cushinoid-like)
      • It takes about a year or so—after a lot of titration—for the pt to start looking normal

Kids Toys (50:16)

When you select toys and play activities for children, there are three things to consider

  1. Is it safe?
  2. Is it age appropriate?
  3. Is it feasible?
    • Is it possible to do easily or conveniently?
    • For instance, swimming in hospital with body cast

Safety

    • Size (no small toys for kids under 4)
    • Over 4 small pieces are fine
    • NO Metal (or dye-cast) if oxygen is in use
      • Think of a flint-sparks!
    • Beware of fomites
      • A fomite is a non-living object that harbors microorganisms, such as stuffed animals—the worst type of fomites
      • Hard plastic toys are fine … They can easily be disinfected

Note

If you have a child who is immunosuppressed … Give them a hard plastic action figure. It can easily be disinfected

Age appropriate toys (See Piaget’s Theory of Cognitive Development on page 79)

Infants

    • 0 to 6 months— Sensorimotor. Best toy is a musical mobile (Best choice) Toy should be large but soft (2nd best choice)

    • 6 to 9 months— Object permanence. Best toy teach them to Cover/Uncover This is to teach them that the object is still there even if they can’t see it

Examples are: Jack-in-the-Box and Peek-a-Boo

Toy should be large but firm

Worse toy after 6 months is the Musical Mobile because of the risk of strangulation

    • 9 to 12 months— Vocalization. Best toys are speaking or verbal toys

Good list of toys are: Tickle me Elmo, Woody Cowboy, See and Say- Barnyard Friends, Talking books

For purposeful play, the infant should be at least 9 months or older

  • These words mean purposeful play: build, sort, stack, make, and construct
  • Baby in womb for 9 months, another 9 months for purposeful play

Toddlers

    • 1 to 3 years— Work on Gross Motor skills, which is running, jumping

Best toys for this age group are Push/Pull toys

Examples are: Lawn mowers, Wagon, dog with floppy feet

They can paint (They use the hand to paint)

They are characterized Parallel Play (think terrible two)

Preschoolers

    • 3 to 6 years— Work on fine motor skills

Therefore, preschoolers have finger dexterity; hence, can write, draw, use colored pencils, scissors

Work on balance—Dance, ice skates, tricycles, tumbling They are characterized by Cooperative Play

  • Need to cooperate in Preschool (= Pretend)
  • You’d be the sheriff, I’ll be robber …

Highly imaginative

School age

    • 7 to 11 years— Concrete

Characterized by the “3 Cs”

  1. Creative—Give them blank paper to draw, they like to get involved … Toys: Legos, Transformers
  2. Collective—Baseball cards, Webkinz, Barbies, Beanie Babies
  3. Competitive—Winner/losers

Adolescents

    • 12 to 18 years— Peer group association

Allow adolescents to be in each other’s rooms unless one of them has been/is

  1. Recently post-op for <12 hrs
  2. Immunosuppressed
  3. Contagious

Note: When given a variety of ages to choose from, always go younger because children regress, when sick you want to give them time to grow

Laminectomy (78:32)

Lamina: the vertebral spinous process (bumpy bones along backbone) Ectomy: removal

Laminectomy is the removal of the vertebral spinous process

Question

Why perform a laminectomy?

    • To relieve nerve root compression … In other words, cutting away the bony prominence gives the nerve more room

Question

What the S/Sx of nerve root compression?

    • The 3 “Ps”
  1. Pain
  2. Paresthesia (tingly)
  3. Paresis (muscle weakness)

When you get a laminectomy question, pay attention to location, location, location

    • There are 3 different locations where laminectomy is performed
  1. Cervical
  2. Thoracic
  3. Lumbar
  4. Cervical—neck
    • What is the most important pre-op assessment for cervical?
      • Cervical innervates the diaphragm and the arms
      • First, assess for breathing
      • Next, check functions of arms/hands
    • Post-op complication
      • Watch for pneumonia
  5. Thoracic—upper back
    • What is most important pre-op for thoracic?
      • Thoracic innervates gut/abdominal muscles … Assess cough and bowels (cannot cough when you cannot contract abs)
    • Post-op complication
      • Pneumonia and paralytic ileus
  6. Lumbar—lower back
    • What is most important pre-op for lumbar?
      • Lumbar innervates Bladder and legs … Assess for urinary retention or last time pt voided or is the bladder empty
      • Next best answer is to evaluate leg functions
    • Post-op complication

o Urinary retention and Leg problems

    • Lumbar = Legs, Urinary retention

Postop Laminectomy

    • Number 1 answer for postop laminectomy, including spinal surgery, is log roll
    • Better pick log roll

Mobilizing pt after laminectomy or spinal surgery

    • Do not dangle these pts—have them seat at the edge of the bed
    • They should go from supine to walking as soon as possible
    • Can they sit on bed long enough to overcome orthostatic hypotension?
      • Yes, but not for 10 to 15 minutes
    • Do not allow pt to sit for more than 30 minutes
    • So, what post-op order would you question for a laminectomy?
      • Up in chair for 1 hour TID
    • These pts may
      • Walk, stand, lie down without restriction

Sitting is bad

Question

You are caring for a pt with a lumbar oligodendrogliocytoma. What is the #1 problem?

  1. Airway
  2. Ileus
  3. Cardiac arrhythmia
  4. Urinary retention

Answer

Who cares what oligodendrogliocytoma is. The lesion is in the lumbar spine. Therefore, we should assess for urinary retention, then for leg problems

    • If the question instead mentions lumbar abscess or lumbar surgery, lumbar ependymoma, the answer would be the same

Note

Recap—Laminectomy

  • Cervical = Neck and Arms
  • Thoracic = Lungs and GI
  • Lumbar = Bladder and Legs

Typically there are no chest tubes with Laminectomy. However, the anterior thoracic will have chest tubes

    • What does anterior thoracic means?
      • From the front through the chest to the spine

Laminectomy with fusion

    • This involves taking a bone graft from (1) the iliac crest and (2) the spine
    • Bone from your hip is taken and put it in place so no bone-to-bone

Questions

Of the two incisions, which site has the most Pain?

    • THE HIP

Of the 2, which one will have/need the most Bleeding/Drainage?

    • THE HIP
    • This is where the HEMOVAC, JP will be

Of the 2, which one has the higher risk of infection?

    • They are equal

Of the 2, which one has the higher risk for rejection?

    • The spine

Since the hip gives more problems, surgeons want to get rid of hip incision. Why?

    • Because, it is shorter recovery … It cuts the infection in half … It decreases the drainage by 80% … Decreases the pain by 80%
    • That is why surgeons are using cadaver bone from banks because the risk of rejection is very low
      • Bone are not protein and protein is what triggers the antigen-antibody response

Discharge Teaching?

There are 4 temporary restrictions and 3 permanent

    • Temporary restrictions … (6 weeks)
    1. Do not sit for >30 minutes
    2. Lie flat, log roll for 6 weeks
    3. Don’t drive for 6 weeks
    4. Don’t lift more than 5 lbs for 6 weeks (gallon of milk) Permanent restrictions
    • Permanent restrictions
  1. Laminectomy patients will never be allowed to lift by bending at waist (use knees)
  2. Cervical laminectomy should never be allowed to lift anything over the head
  3. No horseback riding, off trail biking, jerky amusement park rides, etc. …

Note

This lecture on laminectomy can be used to get any spinal cord question correct … Pay attention to location

Lecture 8 • Mark Klimek • 53:53

You will be asked to prioritize different pts based on lab values

Therefore, it is not good enough to simply know the normal/abnormal lab values You would have to rank or prioritize pts based on abnormally critical lab values

Use the “ABCD” scheme to prioritize pt based on lab values

    • Low priority
      • A is low priority … This lab result can be ignored for a few hours or, if late at night, until very early morning
      • B is concerning … This lab result needs to be closely monitored
    • High priority
      • C is critical … You need to do something for this lab

The RN does the first set of assessments for Levels C or D … Example: V/S, lung and heart auscultations, abdominal exam, etc.

      • D is highest priority … Stay at the bedside

Lab Values (05:11)

Lab Range “ABCD” Scheme
Creatinine (Cr) Best indicator of kidney or 0.6 to 1.2 Level A
renal function Level B if dye procedure
(such as a catheterization) is
involved
INR Monitors coumadin … Also reflects PT (or Prothrombin time) 2 to 3 Level C when 4 and above

Potassium (K+) Blood chemistry

  • Action to take in following order … Hold Coumadin  Focus Assessment for bleeding 

Prepare to give vit K Call HCP

3.5 to 5.3

  • LOW potassium … Action to take in the following order … Nothing to hold Assess heart (EKG)  Prepare to give K+ Call HCP
  • HIGH potassium (bet 5.4 and 5.9) … Action to take in the following order … Hold K+

Assess heart (EKG)  Prepare to give Insulin/Kayexelate Call HCP

  • HIGH potassium (6 or more) … Action to take in the following order … Hold K+ Assess

heart (EKG)  Prepare to give Insulin/Kayexelate STAT Call HCP, stay with pt

Level C if Low Level C if High Level D if over 6

pH Blood chemistry 7.35 to 7.45 Level D if pH in the 6s

 Action to take … Nothing to hold  Assess V/S  Nothing to prepare  Call HCP

BUN Waste product in blood (Blood urea

nitrogen)

 8 to 25 Level A
  • Action to take … Nothing to hold  Assess for dehydration  Prepare IV fluid  Call HCP
Hemoglobin (Hb) Blood 12 to 18 Level B if 8 to 11

Level C if <8
  • Action to take for a Level C … Nothing to hold  Assess for bleeding/anemia/malnutrition

Prepare blood  Call HCP

Bicarbonate 22 to 26 Level A

CO2 Level C if in the 50s

Level D if in the 60s or higher

  • Action to take for a Level C … Nothing to hold  Assess for breathing  Ask pt to perform purse-lipped breathing Call HCP
    • This is not a COPD pt
  • Action to take for a Level D … Nothing to hold  Prepare to intubate/ventilate Call (Respiratory therapy HCP), do not leave pt
    • This is respiratory failure
Hematocrit (Hct) Assess for dehydration 36 to 54 Level B
O2 or PaO2 Blood chemistry 78 to 100 Level C if 70 to 77 Level D if in the 60s or lower, respiratory failure
  • Action to take for a Level C … Nothing to hold  Assess for respiration difficulty and dyspnea, prepare to give oxygen Call HCP
    • In a pt with hypoxia, the heart rate increases first, then the respiratory rate increases afterwards due to compensation
    • In a coronary care unit, the 2 most common episodic causes of tachycardia in heart pt are hypoxia and dehydration

Treatment: Give the O2 to pt and increase the rate of fluid administration usually solve the problem

  • Action to take for a Level D … Prepare to intubate/ventilate pt  (Call Respiratory therapist HCP), stay with pt

O2 Saturation 93 to 100 Level C if <93

  • Action to take for a Level C … Nothing to hold  Give pt O2
  • What invalidates your reading?
    • Anemia
    • Or a Dye procedure—It colors the blood
    • Both falsely elevated
BNP B >100 indicates CHF. Monitor (Brain natriuretic pt for sign of CHF

peptide)

 <100 Level B if >100

Sodium (Na) Electrolyte

Level B if abnormal

Level C if abnormal and there is change in pt’s LOC

135 to 145

    • Action to take for a Level B … Nothing to hold  Assess for fluid overload (hypOnatremia) or dehydration (hypERnatremia)  Prepare for furosemide (hypOnatremia) or IV fluid (hypERnatremia)  Call HCP
    • If there is a change in LOC, pt becomes level C and a safety issue
  • CD4 >200 but <500 is HIV
  • CD4 <200 is AIDS
  • Action for WBC, ANC and CD4 … Assess and put on pt neutropenic precautions

o Refer to neutropenic precautions below

WBC Total 4,000

to 11,000

 Level C <4,000
ANC (Absolute neutrophil count) >500 Level C <500
CD4 >200 Level C <200
Platelet (PLT) 150,000 to

450,000

 Level C if <90,000

Level D if <40,000
RBC

(Red blood cell)

 4 to 6 million Level B if abnormal

Platelet and RBC (Continued onto Lecture 9)

Neutropenic Precautions

Five Deadly “Ds”

  • The following are 5 priority pts based on their lab values
  • The NCLEX exam will not put one of the followings against another
    • K+ >6

o pH in the 6s

    • CO2 in the 60s

o pO2 <60

    • Platelets <40,000
    • Strict hand washing
    • Vital q4 hrs
    • Dedicated stethoscope, BP cuff
    • Reverse/protective isolation
    • Shower BID with microbial soap
    • Avoid crowds
    • Private room
    • Limit staff/visitors
    • No fresh flowers/potted plants
    • No raw fruits/veggies/undercooked meat
    • No water pitcher standing for over 15 minutes
    • Check WBC daily
    • No indwelling catheters
    • Do not reuse cups or disposable plates

Lecture 9 • Mark Klimek • 56:14

Platelet and RBC (Continued from Lecture 8)

Lab Range “ABCD” Scheme
Platelet (PLT) 150,000 to

450,000

 Level C if <90,000

Level D if <40,000
RBC

(Red blood cell)

 4 to 6 million Level B if abnormal

Neutropenic Precautions

Five Deadly “Ds”

  • The following are 5 priority pts based on their lab values
  • The NCLEX exam will not put one of the followings against another
    • K+ >6

o pH in the 6s

    • CO2 in the 60s

o pO2 <60

    • Platelets <40,000
    • Strict hand washing
    • Vital q4 hrs
    • Dedicated stethoscope, BP cuff
    • Reverse/protective isolation
    • Shower BID with microbial soap
    • Avoid crowds
    • Private room
    • Limit staff/visitors
    • No fresh flowers/potted plants
    • No raw fruits/veggies/undercooked meat
    • No water pitcher standing for over 15 minutes
    • Check WBC daily
    • No indwelling catheters
    • Do not reuse cups or disposable plates

Psychiatric Drugs

ALL psychiatric drugs cause low BP and weight changes—usually weight gain

Major Classes Phenothiazines

    • First generation or typical antipsychotics
    • All end in “ZINE”
      • Example: Thorazine, Compazine
    • They don’t cure … They just reduce symptoms
    • We use ZINEs for the ZANY (Cuckoos) … Antipsychotics
    • In small doses, they are antiemetics (to treat vomiting)

Phenothiozines are major tranquilizers

    • Major tranquilizers—big guns psych meds—are Antipsychotics

Analogy

      • Aminoglysoside are to Antibiotics what Phenothiazines are to Antipsychotics
    • Antipsychotics S/Es = “ABCDEFG”
      • Anticholinergic (dry mouth, urinary retention)
      • Blurred vision
      • Constipation
      • Drowsiness
      • EPS (tremors, Parkinson)
      • Foto sensitivity

o aGranulocytosis (low WBC count, immunosuppressed)

Teach patient how to recognize and report sore throat and symptoms of infection

Question

    • What is the nursing action when someone presents with a S/E?
      • Educate

Question

    • What is the nursing action when someone presents with a Toxic effect?
      • HOLD the drug  Notify HCP

Note

    • The #1 nursing diagnosis for “ABCDF” S/Es is to teach pt about SAFETY
    • The #1 nursing diagnosis for “G” S/Es is to teach pt to report signs of infections to HCP

Decanoate or “Caprate” form of a medication

    • The long-acting form of a drug
    • Sometimes denoted with the letter “D”
    • IM form given for non-compliance
    • Often Court-ordered

Tricyclic Antidepressants

    • Grandfathered into the NSSRI (Non-selective serotonin reuptake inhibitor) group
    • Mood elevators (Happy pills)
    • Elavil (elevates), Trofranil, Aventyl, Desyrel
      • Elevates the mood
      • Side effects of TCA are Anticholinergic (especially, dry mouth) Blurred Vision

Constipation Drowsiness Euphoria (happy)

Must take meds for 2 to 4 weeks for beneficial effects

    • So, after the first week of antidepressant therapy, pt will complain the drug is not working
    • Teach pt that the medication takes about 2 to 4 weeks to reach therapeutic effects

Benzodiazepines

Naming of antipsychotics

  • If you want to put someone asleep, give him the ZZzzs
  • Zines for the Zany (major antipsychotics)
  • Zeps for the minor antipsychotics

o If you are old enough, you may answer that question … What do you find at a Zeppelin concert?

Minors on tranquilizers

    • Anti-anxiety, minor tranquilizers
    • Always have ZEP in the name
    • Remember ZZzzs for falling/going to sleep
    • Many benzodiazepines end in “Pam” or

“Lam”

    • Prototype: Valium, induction of anesthetic, muscle relaxant, alcohol
    • Can be used as
      • Seizures medications
      • Preop induction of anesthesia
      • Muscle relaxants
      • EtOH withdrawal medications
      • Ventilation—medication to relax and calm down pts on a ventilator
    • Benzos work quickly … But do not take them for more than 2 to 4 weeks

Administer major and minor tranquilizers at the same time. Why?

    • The major antipsychotics take a long time to start working
    • The minor antipsychotics start working right away
    • Both are administered at the same time
    • Example: pt is usually put on Valium and Elavil at the same time
      • Valium is discontinued in 2 to 4 weeks once Elavil kicks in

Note

A similar example for giving major and minor tranquilizers together is the concurrent use of Heparin and Coumadin (warfarin)

    • Heparin works right away but a pt should not be on it for a long time
    • Coumadin takes a few days to start working but a pt can be on it for the rest of his life

S/Es of Benzodiazepines are “ABCD”

    • Anticholinergic
    • Blurred Vision
    • Constipation
    • Drowsiness

Monamine Oxidase (MAO) Inhibitors

    • Antidepressant
    • Depression is thought to be caused by norepinephrine, dopamine, and serotonin in brain
    • Name of MAOIs starts with
    • MARplan, NARdil, PARnate the beginnings—all rhyme
    • S/E of MAOIs
      • Anticholinergic
      • Blurred Vision
      • Constipation
      • Drowsiness

Teaching Points

    • Avoid tyramine-containing food … May cause Hypertensive Crisis
    • Food with tyramine
      • Fruits/Veggies—Avoid salad “BAR”: Bananas, Avocados (guacamole), Raisins (dried fruit)
      • Grains—Ok to have, except Yeast
      • Meats—No organs liver, kidney, tripe, heart, no preserved meats (smoked, dried, cured, pickled, hot dogs)
      • Dairy—No chees except for mozzarella, cottage cheese (no aged cheese)
      • No EtOH, elixirs, tinctures (iodine/betadine) caffeine, chocolate, licorice, soy sauce

Lithium

    • Used for treating Bipolar disorder—it decreases the mania LI = BI
    • S/E: Very Unique—acts more like an electrolyte—think: Potassium/Lithium
    • The 3 Ps as S/Es
      • Peeing (Polyuria)
      • Pooping (diarrhea)
      • Paresthesia (earliest sign of electrolyte imbalance)

The earliest sign of electrolyte imbalance is Paresthesias = Numbness and Tingling

Toxic effects of lithium

    • Tremors
    • Metallic taste
    • Severe diarrhea

Question

What is the #1 nursing intervention in a pt on lithium presenting with peeing/pooping all the time?

    • #1 intervention
      • Give pt fluids
    • The above S/Sx are S/Es—expected
    • Monitor sodium
    • Low sodium makes lithium toxic
    • High makes lithium ineffective
    • Sodium needs to be normal

Question

What is the #1 nursing intervention in a pt on lithium presenting with metallic taste and severe diarrhea?

    • #1 intervention
      • Give pt fluids
    • Notify the HCP—this is a toxic effect

Prozac (fluoxetine)

    • SSRI, mood elevator
    • Side effects of Prozac are
      • Anticholinergic
      • Blurred Vision
      • Constipation
      • Drowsiness
      • Euphoria (happy)

Causes insomnia so give before noon. If bid, give at 6 a.m. and noon

    • When changing doses, watch for suicidal risk in adolescents
      • Must recently change the dose and be an adolescent of young adult

HALDOL (haloperidol)

    • Tranquilizers (basically same as Thorazine)
    • S/E of Haldol
      • Anticholinergic (dry mouth, urinary retention)
      • Blurred vision
      • Constipation
      • Drowsiness
      • EPS (tremors, Parkinson)
      • Foto sensitivity

o aGranulocytosis (low WBC count, immunosuppressed)

Teach patient how to recognize and report sore throat and symptoms of infection

    • First generation antipsychotics
    • Pts may develop NMS (neuroleptic malignant syndrome) from overdose
      • Seen in elderly and young white schizophrenic pts
      • High fever over 105
      • Their doses should be about ½ usual adult dose

Question

A pt is being treated with an antipsychotic medication. Pt becomes anxious and presents with tremors. What is the nurse intervention to differentiate NMS (neuroleptic malignant syndrome) from EPS (extrapyramidal syndrome)?

    • Measure the pts’ temperature
      • If temperature is WNL, this is EPS
      • If temperature is 102 and rising, call the emergency response team and notify HCP … NMS is lifethreatening
    • NMS presents with anxiety and tremors, and so does EPS

Note: With Haltol, there are safety concerns related to the S/Es

Clozaril (clozapine)

    • Atypical antipsychotic
    • Advantage it does not have A-F side effects
    • Don’t confuse it with Klonopin/Clonazepam!
    • S/Es of clozapine

o aGranulocytosis! It is worse than cancer drugs and can trash the pt’s bone marrow

Note

    • Geodon (ziprasidone) has a black box warning
    • Prolong the QT interval, which can cause sudden cardiac arrest
    • Do not use in pts with cardiac condition

Note: Second generation antipsychotics end in “Zapine”

Question

What is the #1 nursing intervention in a pt taking Clozaril (clozapine)

    • Monitor the WBC

Zoloft (Sertraline)

    • Antidepressant
    • Can cause insomnia
    • Interact with the followings because they are not metabolized in the liver
      • St. John’s Wort and cause serotonin syndrome
      • Warfarin and cause bleeding
    • S/E of serotonin syndrome is “SAD Head”
      • Sweating
      • Apprehensive (impending sense of doom)
      • Dizzyness
      • Headache

Note: The nurse should anticipate lowering the dose of sertraline (Zolof) of a pt on St. John’s Wort and Warfarin

Lecture 10 • Mark Klimek • 87:50

Maternity and Neonatology

Determining the estimated date of delivery

    • Use the Naegele rule—take first day of last menstrual period (LMP), add 7 days and subtract 3 months from it
      • For instance, if the last menstrual period of a pt was between June 10 and 15
      • The estimated date of delivery = March 17

Weight gained during pregnancy

If weight gained during pregnancy is within

 +/–1 to 2 lbs of the ideal weight for the gestational week … Pt is WNL

If weight gained is within

 +/–3 lbs … Assess her

 +/–4 lbs or more… There is trouble

o perform a BPP on the fetus

    • 1st trimester (12 weeks)
      • 1 lb per month = Total of 3 lbs
    • 2nd and 3rd trimesters
      • Add 1 lb every week
    • The ideal weight gained during pregnancy
      • 28 lbs, plus or minus 3
      • Between 25 to 31 lbs

Alternative method

A quick and dirty way to come up with the ideal weight gained during pregnancy is to

    • Take the number of weeks gestation minus 9

Question

A woman is in her 28th week gestation. She gained 22 lbs, what is your impression?

    • Using the long method
      • First trimester (12 weeks) … She gained 3 lbs
      • 28 weeks minus 12 weeks = 16 weeks
      • Therefore, she would add an extra 16 lbs on her weight
      • 3 + 16 = 19 lbs … She has 3 lbs extra than her ideal weight
      • Therefore, assess the pt
    • Alternatively, subtract 9 from the number of weeks gestation

o 28 – 9 = 19 lbs

Question

A pregnant woman at 31 weeks gestation gained 15 lbs. what is your impression?

    • Using the short method, this pt ideal weight should be

o 31 – 9 = 22 lbs

      • However, 22 – 15 = 7 lbs less than the ideal
      • Therefore, the nurse needs to assess the biophysical profile (BPP) on the fetus

Fundal Height

    • Fundal height cannot be palpated until week 12
      • That when the fundus is midway between the umbilicus and the pubic symphysis
    • The fundus can be palpated at the umbilicus between 20 and 22 weeks

What is the significance of being able to palpable fundal height?

    • The examiner should be able to determine in what trimester the pregnancy is
      • In case pt is unconscious, for instance
      • It has diagnostic significance as well … A much bigger than normal fundus may indicate molar pregnancy

Positive Signs of Pregnancy

The Boards test positive signs and everything else

  1. Fetal skeleton on x-ray
  2. Presence of fetus on ultrasound
  3. Auscultation of fetal heart (Doppler)
  4. Examiner palpates fetal movement (outline)
    • Not the mother but the examiner

Ranges of Values

In OB, there are 3 types of questions regarding range of values

For instance, the fetal HR can be heard first between 8 to 12 weeks gestation Quickening (baby Qicks) may be first felt between 16 to 20 weeks gestation Therefore, if the question ask

When would you first?

      • Fetal Heart: 8 weeks
      • Quickening: 16 weeks
      • This is the earliest date

When would you most likely?

      • Fetal Heart: 10 weeks
      • Quickening: 18 weeks
      • This is the date midway in the range

When should you by?

      • Fetal Heart: 12 weeks
      • Quickening: 20 weeks
      • This is the latest date

Maybe Signs of Pregnancy

  1. Positive urine/blood hCG tests
    • A positive pregnancy test may result from other conditions
    • For instance, cancer
  2. Chadwick sign—cervical color change to cyanosis (Cs)
    • Bluish discoloration of the vulva, vagina and cervix

Goodell sign—good and soft

    • Softening of the cervix

Hegar sign—uterine softening

    • Softening of lower uterine segment

Chadwich  Goodells  Hegar

    • All 3 signs are in alphabetical order and
    • Move up from the vulva, vagina, cervix to the uterus

Patient Teaching for Prenatal Visit

During pregnancy, pt is advised to go for prenatal visits as follows

    • Once a Month until week 28
    • Every other week between 28 and 36
    • Once a week after week 36 until delivery or week 42, whichever comes first
      • At week 42, delivery can be induced or by C-section

Question

If a woman comes in for her 12th week prenatal checkup, when is her next prenatal visit?

    • Her next visit is at 16 weeks

Lab Values

UWorld

Hemoglobin (Hb)

  • 1st & 3rd trimester
    • 11 g/dL
  • 2nd trimester
    • 10.5 g/dL
  • If Hb <9, anemia evaluation

Hemoglobin (Hb) level will fall during pregnancy

    • Normally Hb in female = 12 – 16
    • A pregnant woman can tolerate lower levels of Hb
    • First Trimester: Hb can fall to 11 and be perfectly normal
    • Second Trimester: Hb can fall to 10.5 and be perfectly normal
    • Third Trimester: Hb can fall to 10 and be perfectly normal

Question

How do you treat morning sickness?

    • Morning sickness is usually seen during the 1st trimester
    • Treatment: Dry carbohydrates—not before breakfast but—before pt gets out of bed

Question

How do you deal with urinary incontinence?

    • Urinary incontinence is seen in the 1st and 3rd trimesters
    • Pt needs to void every 2 hours from the day she gets pregnant until 6 weeks postpartum

Question

A pregnant pt complains of difficulty breathing. What should you advise her to do?

    • Difficulty breathing is a problem during the 2nd and 3rd trimesters
    • Advise pt to assume to tripod position
      • Tripod position is a physical stance often assumed by people experiencing respiratory distress

Figure 7. Tripoding.

      • The pt will be leaning forward with hands on knees or the surface of a desk or table

Question

A pregnant pt complains of back pain. What should you advise her to do?

    • Back Pain is seen during the 2nd and 3rd trimester
    • Advise pelvic tilt exercises to pt

Labor and Birth

What is the truest most valid sign that she is in labor?

    • The truest most valid sign of labor is the

onset of regular/progressive contractions

To Know

    • Dilation is opening cervix from 0 to 10 cm
    • Effacement is thinning of the cervix. It goes from thick to 100% efface (thin like paper)
    • Station is the relation between fetal presenting part and the mother’s ischial spines (know this)—the narrowest part of the pelvis
      • Positive numbers mean the baby has made it through this tight squeeze—good to go

Positive numbers = Positive news

      • If a baby stays at a –3, –2, –1, it can’t get through vaginally. It needs C-section for delivery
    • Engagement is station zero—this means the presenting part is at the ischial spines

Lie is relationship between the spine of the mother and spine of the baby

    • You want a vertical lie—compatible with vaginal birth
      • If the mother’s spine and the baby’s spine is parallel—we got a baby
    • If lie is perpendicular—tranverse lie = Trouble … C-section
      • If we got them perpendicular, we’ve got trouble—T

Most common presentation is ROA or LOA—that’s the guess—don’t bother memorizing

    • ROA (right occiput anterior)

Note

Before giving digitalis, always take an apical HR (heart rate)

    • LOA (left occiput anterior)
    • Pick ROA before LOA

Delivery of the Fetus and the Placenta

    • There are 4 stages of labor

Stage 1 Onset of Labor—It has 3 phases

    • Latent—cervical dilation from 0 to 4 cm
      • Phase 1
      • Contractions are 5 to 30 minutes apart, lasting 15 to 30 seconds
      • Mild intensity
    • Active—cervical dilation from 5 to 7 cm
      • Phase 2
      • Contractions are 3 to 5 minutes apart, lasting 30 to 60 seconds
      • Moderate intensity
    • Transition—cervical dilation from 8 to 10 cm
      • Phase 3
      • Contractions are 2 to 3 minutes apart, lasting 60 to 90 seconds
      • Strong intensity

Question

A pregnant woman comes in to L&D (labor and delivery). She is 5 cm dilated, with contraction 5 minutes apart, lasting 45 seconds. What phase of labor is the pt in?

    • The pt is in ACTIVE phase

One good studying strategy to use for memorizing the 3 phases of Stage 1 labor is to know everything about the Active (or Phase 2) of Stage 1

    • Once you know the upper and lower limit values, you can deduce the values of Phase 1 and Phase 3
      • Phase 2 — Contractions: 3 to 5 minutes and last 30 to 60 seconds

Stages and Phases of Labor

    • Stage 1—Onset of Labor  Cervical Dilation and Effacement
      • Phase 1—Latent
      • Phase 2—Active
      • Phase 3—Transition
    • Stage 2—Delivery of Baby
    • Stage 3—Delivery of Placenta
    • Stage 4—Recovery: 2 hours until bleeding stops

HESI Questions

What is purpose of uterine contraction in first stage?

    • Dilation and effacement of the cervix What is the purpose in 2nd stage?
    • Delivery of baby

What is the purpose 3rd stage?

    • Delivery of placenta

What is the purpose of 4th stage?

    • Stop bleeding

When does postpartum technically begin?

    • 2 hours after delivery of placenta

Pay attention to whether the question is asking about stages or phases

    • There are 4 stages
    • There are 3 phases, which are part of Stage 1

Questions

What is the #1 priority of second phase?

    • Pain management

What is the #1 priority of second stage?

    • Clearing baby’s airway

Questions

What is the #1 priority of third phase?

    • Checking cervical dilation, Helping pregnant mother with breathing and pain management What is the #1 priority of third stage?
    • Assess the placenta for smoothness and intactness, and for 3-vessel (not 2) umbilical cord present

Stages and Phases of Labor

    • Stage 1—Onset of Labor
      • Phase 1—Latent … Dilation from 0 to 4 cm

Contractions are 5 to 30 minutes apart, lasting 15 to 30 seconds

Mild intensity

      • Phase 2—Active … dilation from 5 to 7 cm

Contractions are 3 to 5 minutes apart, lasting 30 to 60 seconds

Moderate intensity

      • Phase 3—Transition … dilation from 8 to 10 cm

Contractions are 2 to 3 minutes apart, lasting 60 to 90 seconds

Strong intensity

    • Stage 2—Delivery of Baby
    • Stage 3—Delivery of Placenta
    • Stage 4—Recovery: 2 hours until bleeding stops

Memorize for the following 3 quetions

Uterine contraction should be no longer than 90 seconds and no closer than 2 minutes

Questions

What is a sign of uterine tetany?

    • No longer than 90 seconds and no closer than 2 minutes

What parameters regarding uterine contraction would make you stop Pitocin?

    • No longer than 90 seconds and no closer than 2 minutes

What is uterine hyperstimulation?

    • No longer than 90 seconds and no closer than 2 minutes

Know that phrase

    • No longer than 90 seconds and no closer than 2 minutes

Assessment of frequency of contraction

    • Frequency is from the beginning of one contraction and beginning of the next

Assessment of duration of contraction

    • Duration of contraction is from the beginning to end of one contraction

Intensity of labor

    • Assessment of intensity of labor is purely subjective

Teach her how to palpate with one hand over the fundus with the pads of the fingers

Complications of labor

    • There are 18 complications
    • Know them all
    • But only 3 protocols—focus on the 3 protocols

Painful Back pain—“OP” = Oh Pain. What do you do?

“OP” … Anything (right or left) occiput posterior

    • Position—Push
    • What position?
      • KNEE-CHEST position then
      • PUSH with fist into sacrum to use counter pressure

Prolapsed Cord

    • Push head in off cord and position knee-chest or Trendelenburg
    • Prep for C-section
    • Think PUSH/POSTION
      • Push head off the cord of fetus and position mother to knee-chest

Interventions for all other complications

    • Tetany
    • Maternal hypertension
    • Vena cava syndrome
    • Toxemia
    • Uterine rupture
    • All treated the same—with “LION”
      • Left side (place mother on the left side)
      • IV
      • Oxygen
      • Notify HCP
    • Stop Pitocin (pit) if it was running—the first thing to do

Implement before “LION”

Figure 8. Knee-chest position.

    • In an OB crisis, if pitocin is running, stop it first. Then, implement “LION”

When to administer systemic pain medication

    • Do not administer a systemic pain medication to a woman in labor if the baby is likely to be born when the med is at its peak … For example

Questions

    • You have a primagravida at 5-cm dilated who wants her IV push pain med. What is the nursing intervention?
      • Hold the pain medication
      • This is because the pt is primagravida and will deliver in about 15 to 30 minutes when the medication peaks
    • You have a multigravida at 8-cm wants her IM pain med. What is the nursing intervention?
      • Do not administer the pain medication Labor and Delivery (Continued onto next lecture)

Lecture 11 • Mark Klimek • 78:29

Labor and Delivery (Continued from previous lecture)

Fetal Monitoring Patterns

There are 7 fetal monitoring patterns to learn … The ones that start with the letter “L” are bad heart tracings. Use the mnemonic “LION” as the nursing intervention

Normal fetal heart rate = 120 to 160 beats per minutes

Low Fetal HR (heart rate)—HR <110

    • This is BAD
    • You do “LION”
      • Left side (place mother on the left side)
      • IV
      • Oxygen
      • Notify HCP
    • Stop Pitocin (pit) if it was running
      • Implement before “LION”

High Fetal HR—HR >160

    • Document acceleration of fetal HR
    • Take the mother’s temp
    • Not a high priority … Baby is WNL

Low Baseline Variability

    • This is BAD
    • Fetal HR stays the same—it doesn’t change
    • You do “LION”
      • Left side
      • IV
      • Oxygen
      • Notify HCP
    • Stop pit if it is running (first)

Figure 9. Remember “VEAL CHOP” for the causes of 4 HR patterns.

High Baseline Variability

    • Fetal heart rate is always changing—This is GOOD
    • Document finding

Note

In utero, low variability of V/S is a bad sign but highly variable V/S is a good sign

Early Deceleration

    • This is normal … No big deal
    • Document finding

Variable (VERY) Decelerations

    • This is very BAD
    • This indicates prolapsed cord
    • What is the nursing intervention?
      • PUSH and POSITION

Late Decelerations

    • This is BAD
    • You do “LION”
      • Left side
      • IV
      • Oxygen
      • Notify HCP
    • Stop pit if it is running

Recap

    • Look at the first letter of a fetal heart rate tracing, it is a bad heart tracing if it starts with an “L”
      • Therefore, do “LION” which also starts with the letter “L”
    • Variable deceleration is very bad
      • PUSH and POSITION)
    • Ace of spades means that this answer works every time
      • Check the FHR

Second stage of L&D (labor and delivery)

    • Delivery of the fetus … This is about order.
  1. Deliver head … The mother needs to stop pushing
  2. Suction the mouth then the nose … ABC order
  3. Check for nuchal (around the neck) cord
  4. Deliver the shoulders, next, the body
  5. Make sure baby has ID band on before it leaves the delivery area

Third stage of L&D

    • Delivery of the placenta
    • What do you check for with the delivery of the placenta?
      • Make sure the placenta is complete and intact
      • Check for 3-vessel cord—2 arteries and 1 vein, AVA

Fourth Stage of L&D

    • Recovery
    • There are 4 things you do in the 4th stage, 4 times an hour (every 15 minutes)
  1. Vital signs: Assessing for shock … Blood pressure goes down, HR goes up … Pt looks pale, cold, and clammy
  2. Fundus: If it is boggy, massage it … If displaced, catheterize it
  3. Check perineal pads … If there is excessive bleeding, the pad will saturate in 15 minutes or less
  4. Roll pt over and check for bleeding underneath her

Recap

    • 4 things to do every 15 minutes in the 4th stage of labor
      • V/S  Fundus  Peri pads  Roll

Post partum Assessment

    • Assess every 4 to 8 hours
    • Assess for “BUBBLE HEAD”
    • Make sure you focus on the 3 designated steps stated as important from BUBBLE HEAD

“BUBBLE HEAD” stands for

    • Breasts
    • Uterine fundus should be firm … Important
      • Massage if fundus is boggy and midline
      • Catheterize pt if fundus is boggy and not midline

Question

What should the postpartum uterine tone, height, and location normally be?

    • The tone of the fundus should be firm, not boggy
    • The height of the fundus after delivery should be at the umbilicus (or navel)
      • Fundus involutes about 2 cm every day PP (postpartum)
    • The location of the uterus should be midline
      • If not midline, the bladder is distended
    • Bladder

    • Bowel
    • Lochia is vaginal drainage postpartum (Know the order) … Important
      • Rubra—red
      • Serosa (if your cheeks are rosy)—pink
      • Alba (albino)—white
      • Moderate amount: 4 to 6 inches on pad in an hour
      • Excessive: saturate a pad in 15 minutes
    • Episiotomy
    • Hemoglobin/hematocrit

Figure 10. Fundal height postpartum.

    • Extremities—Looking for thrombophlebitis … Important
      • What is the best way to determine if a pt has thrombophlebitis?

The best way is to measure Bilateral calf circumference (Best answer)

Homan sign is not the best answer

    • Affect—emotional
    • Discomforts

Recap

The 3 big things about postpartum on the exam are

    • Fundus
    • Lochia
    • Thrombophlebitis

Variations in the newborn

All of the following skin conditions are normal

    • Milia—White, pinhead-size, distended sebaceous glands on the nose, cheek, chin, and occasionally on the trunk. Usually disappear after a few week of bathing
    • Epstein pearls—Palatal cysts of the newborn, which are small white or yellow cystic vesicles
    • Mongolian spot—Bluish discoloration in the sacral region of newborn usually seen in African Americans … Carefully document its presence as such action may prevent child abuse charges against parents or caregiver
    • Erythema toxicum neoratorum—Described as flee-bitten lesion … pink rash with firm, yellow-white papules or pustule on the face, chest, abdomen, back and buttocks of some newborns. Usually appears 24 to 48 hours after birth and disappear in a few days
    • Hemangioma—An abnormal accumulation of blood vessels in the skin of the newborn. It is one of the most common birthmarks associated with childhood and affect 10% of all children

Milia Epstein pearls Mongolian spot Erythema

toxicum neonatorum

Hemangioma

Cephalohematoma vs. Caput succedaneum … Make sure you know these 2

    • Cephalohematoma—A collection of blood between the periosteum of a skull bone and the bone itself
      • Occurs in one or both sides of the head
      • Occasionally forms over the occipital bone
      • Develops within the first 24 to 48 hours after birth
    • Caput succedaneum—An edema of the scalp of the neonate during birth from mechanical trauma of the initial portion of scalp pushing through a narrowed cervix
      • The edema crosses the suture lines
      • May involve wide areas of the head or it may just be a size of a large egg
      • Caput Succedaneum (CS)—Crosses Suture line, and Caput Symmetrical Cephalohematoma Caput succedaneum

Caput Succedaneum (CS)—Crosses Suture line, and Caput Symmetrical

Hyperbilirubinemia in the Newborn

    • Physiologic jaundice is normal and appears after 24 hours after birth … Disappears in about one week
    • Pathologic jaundice is seen in the 1st 24 hours after birth

Vernix caseosa

Fatty, whitish secretion of the fetal sebaceous gland to protect the skin from amniotic fluid exposure

Acrocyanosis

Blue discoloration of the hands and feet in the newborns during the first few days after birth

    • Normal finding

and not indicative of poor oxygenation, respiratory distress, or cold stress

Nevi (Telangiectatic nevi)

Nevi or telangiectatic nevi, a.k.a. “stork bites,” are pink and easily blanched skin lesion that appear on upper eyelid, nose, upper lip, lower occipital area, and nape of the neck

    • No clinical significance
    • Disappears by 2 years of age

Port wine stain

Port-wine stain or nevus flammeus is seen at birth and is composed of a plexus of newly formed capillaries in the papillary layer of the corium

    • Commonly found on the face and neck
    • Red to purple, varies in size, shape and location
    • Does not blanch on pressure

OB Medications—6

    • Terbutaline (Brethine)
    • Mag sulfate
    • Pitocin
    • Methergine
    • Bexamethasone
    • Surfactant

Tocolytics (Stop contractions, stop labor)

    • Tocolytics are given to women in premature labor that must be stopped
    • Terbutaline (Brethine)
      • S/E: maternal tachycardia (don’t give with cardiac disease)
    • Mag sulfate
      • Treatment with Mag sulfate will induce hypermagnesemia, which will cause everything to go down
      • HR will go down, BP go down, Reflexes go down, RR go down, LOC go down

Question

So, what is the nursing intervention for hypermagnesemia due to mag sulfate treatment?

    • Monitor respiration
      • If RR <12, decrease dose of Mag sulfate
    • Assess for reflexes
      • Normal reflex is 2+
      • If reflexes are 0 or 1+ … Decrease dose of mag sulfate
      • If reflexes are 3+ or 4+ … Increase dose of mag sulfate

Oxytocics (Stimulate and strengthen labor)

    • Pitocin (Oxytocin)
      • S/Es: Uterine hyperstimulation (defined as longer than 90 seconds, closer than 2 minutes) The nursing intervention is to lower the dose of pitocin in case of uterine hyperstimulation
    • Methergine
      • Causes HTN—if it contracts blood vessels it makes sense that this increases BP

Fetal/Neonatal Lung Meds

    • Betamethasone (steroid)
      • Given to mother IM
      • Can repeat as long baby is in utero
      • S/E: increase glucose (steroid)
    • Surfactant (Survanta)
      • Given to baby via transtracheal route
      • Given After birth

Medication Helps and Hints

  1. What is Humalin 70/30?

Mix of insulin N and R … 70% = N … 30% = R

      • So, if 100 units of 70/30 is given to a pt … the pt gets 70 units of N and 30 units of R
      • Or, for 50 units—35 units of N and 15 units of R
      • To remember the bigger number, think of a fraction … The numerator N is on top; therefore, Insulin N is the bigger number

Question

Can you mix insulin in same syringe and how?

    • Yes, insulin can be mixed in the same syringe
    • How do you mix insulin?
      • (1) Pressurize vial and (2) Draw up insulin
  1. To pressurize the vial … Inject air into N, the into R, Draw up R
  2. To draw up insulin … Think of RN

Needle for Insulin Injections

    • Know what needle to use for insulin injection?
    • Giving an IM injection
      • Pick answer in which both answers have a “1” in them
      • “I” in IM looks like the “#1”
      • Use a 21-gauge, 1-inch long needle
    • Giving a SubQ injection
      • 5 looks like an “S” in “SubQ”
      • Pick the answer that has “5s” in it
      • Use a 25-gauge, 0.5 inch needle

Heparin

    • Given IV or SubQ
    • Works immediately

Figure 11. Pressurizing vials with air and drawing up insulin.

    • Cannot be given for more than 3 weeks (21 days)

After 21 days the body start making antibodies against heparin. Therefore, it is not given for more than 21 days

o Except for Lovenox (enoxaparin)

    • Antidote: Protamine sulfate
    • Labs: PTT
    • Can be used during pregnancy— Class C medication

Coumadin

    • Given only PO
    • Takes few days to a week to work (likely 4 to 5 days)
    • Pts can be on Coumadin for their entire life
    • Antidote: Vitamin K
    • Labs: PT/INR
    • Can’t be used during pregnancy— Class X medication

Note: The only antipsychotic that can be given to pregnant women is Haldol

Diuretics

    • K-wasting and K-sparing diuretics
    • Any diuretic ending in “X,” “Xes” out K
      • So, it wastes “K” like Lasix
      • PLUS Diuril
    • If it does not end in “X,” it is a sparer
    • Examples

Brand Generic

      • Aldactone Spinorolactone
      • Adactazide Spinorolacone-Hydrochlorothiazide
      • Modurectic Amiloride-Hydrochlorothiazide
      • Lasix Furosemide
      • Bumex Bumetanide
      • Clotrix Clotrimazole
      • Esidrex Hydrochlorothiazide
      • Demadex Torsemide
      • Diuril Chlorothiazide

Baclofen and Cyclobenzaprine

    • 2 muscle relaxants to know for the NCLEX

Brand Generic

      • Lioresal Baclofen
      • Flexeril Cyclobenzaprine
    • The 2 things being tested on the board are
      • The 2 S/Es
  1. Fatigue/Drowsiness
  2. Muscle weakness (paresis)
      • The 3 things to teach
  3. Don’t drink
  4. Don’t drive
  5. Don’t operate heavy machinery

Note: The following phrase help you remember baclofen as a muscle relaxant … “When you are on baclofen, you are on your back loafing”

Pediatric Teaching

Piaget’s Theory of Cognitive Development—4 Stages

    • There is some overlap with Piaget’s Theory of Cognitive Development and toy appropriateness based on age on page 50
    • Make sure not to confused between the two

Sensorimotor—0 to 2 years

    • They only think about what they are sensing right now
    • You can teach only in the present (while you are doing it)

Think Present Tense

      • Just tell them
      • Children at this age don’t understand play
      • Tell them as it is happening

Question

A 19-month-old infant is about to have a lumbar puncture (LP) for csf analysis and culture. How would the nurse teach the child?

    • Tell the child how the LP is done while it is being done.
    • There is no such thing as preop teaching for this age group
    • Preop teaching are only for the parents—mom and dad—or guardian

Preoperational (Preschooler)—3 to 6 years

    • They are fantasy-oriented, imaginative, and illogical, there thinking obeys no rules
    • However, they understand the future and they understand the past

Question

A 3-year-old child is schedule for a lumbar puncture (LP) for csf analysis and culture. What is the nurse’s best action to teach the child about the procedure?

    • Teach 2 hours before …, the morning of …, or the day of the procedure how it will be performed
    • They are in the “imaginative” stage … Don’t give them a whole lot of time to imagine the worst
    • Teach them what will be done … Future Tense
    • They can learn by playing

Concrete Operations—7 to 11 years

    • “7/11 Grocery Stores are surrounded by concrete”—no trees, no flowers
    • Children in this age group are rule-oriented

Live and Die by the Rules and Cannot Abstract

      • There is one way to do things … Everything else is wrong
    • Teach them a day or two ahead of time
    • Teach them what you’re going to do and how to do skills
    • Use age-appropriate reading and demonstration (skill)

Question

An 8-year-old child is schedule for a lumbar puncture (LP) for csf analysis and culture. What is the nurse’s best action to teach the child about the procedure?

    • Use age-appropriate demonstration 1 or 2 days before the procedure

Formal Operations—12 to 15 years

    • They can abstract and think Cause and Effect

As soon as children become twelve, teach them like an adult

      • This is now a regular Med-Surge question
    • When is the first age a child can manage his care?
      • 12 years old
      • Manage means making decisions which require the person to abstract

Question

Which of the following 4 children will be able to manage his own care?

  1. A 7-year-old with Cystic Fibrosis
  2. An 8-year-old with Diabetes Mellitus
  3. A 10-year-old with a scraped knee
  4. A 13-year-old with Chronic Renal Failure

Answer: (d)

    • A 10-year-old with a scraped knee as one of the answer choices is a diversion to fool the exam taker. Answer to these questions is not about the severity of the condition but about the age- appropriateness to make decision
      • The 10-year-old will Wash, Dry, apply Neosporin and Bandaid the wound as thought … He will continue to do the same thing if the wound becomes is exudating pus and swollen the 4th day … A 12-year-old will likely stop and seek help
    • A 13-year-old with chronic renal failure will get help if they are thought to auscultate for a bruit over a shunt and heard nothing on day 3
      • This is managing
      • This means that knowing what you can do when you can, and seek help when you cannot

Note: Manage = 13-year-lod … Skill = 8-year-old

Seven Principles to Obey When Taking Psychiatric Tests

  1. Make sure you know what phase of the nurse-patient relationship you are in

  1. Don’t give/accept gifts in psych
    • If a schizophrenic pt gives you flowers, to you the HCP it may be flowers; to him, it may be a marriage proposal
  2. Don’t give advice!
    • If the pt says, “What do you think I should do?” Reply by asking them the same question” “What do you think you should do?”
    • The pt won’t be able to blame you in the future even if things work in his favor
    • Avoid giving advise in psych
  3. Never give guarantees
    • For instance, “If you cry, you will feel better.”
    • There are chances that crying may not help the pt
  4. Immediacy
    • If you are between 2 answer choices and you don’t know which one to pick, pick the one

that keep him talking

    • Don’t refer to someone
  1. Concreteness
    • Psych pts take you literally. Therefore …
    • Never use slang
    • If a pt says “I feel rotten.” Don’t reply by saying, “You feel rotten?”
    • Don’t ever say to an upset pt to “Chill out!”
    • Don’t use figurative speech such as: “What goes around, comes around”
  2. Empathy
    • Empathy is about the nurse accepting the patient’s feelings
    • Don’t ever pick an answer that says, “Don’t you worry …” … “You shouldn’t feel …” … “Anybody would feel …” … “I know how you feel …” …

4 steps to answering empathy questions

  • Empathy questions will always have a quote
  • Role play the feelings (Put yourself in their place) and say the words as you really meant them
  • Ask yourself if I said these words, how would I be feeling right now?
  • Choose the answer that reflects the pt’s feeling, and ignore what the pt said

Lecture 12 • Mark Klimek • 124:17

Prioritization, Delegation and Staff Management

  • This is the most important lecture in the whole review
  • There will be at least 15 questions on this section alone
  • Most exam takers dead guess in the section
  • Learn the material and do not guess

Prioritization

Prioritize—you are deciding which pt is sickest or healthiest… Make sure you know what you’re looking for

Question

For instance, if the question states that there was a disaster in town and you are making room for the wounded, who would you discharge?

  • In that case, would you be looking for the highest or lowest priority pt?
  • Answer: the lowest priority pt

Question

However, if the question states that you receive handoff end-of-shift reports on 4 pts. Which pt will you check first?

  • Answer: the highest priority pt

Answers will usually have 4 parts

  • (1) Age, (2) Gender, (3) Dx, and (4) a modifying phrase
  • For example: A 10-year-old male with hypospadias is throwing up bile stained emesis
    • Age: 10-year-old
    • Gender: male
    • Diagnosis (Dx): hypospadias
    • Modifying phrase: throwing up bile stained emesis
  • 2 of which are irrelevant for answering the question
    • Age and gender are not important in prioritization
  • Age is important in pediatrics
  • Of all 4 parts, the modifying phrase is more important

Remember

The modifying phrase is always the most important

Example

Two pts: one has angina pectoris and the other myocardial infarction. Who has the higher

priority pt?

  • Answer: The MI pt
  • Go by the patient’s condition since there is no modifying phrase

Example

Now modifying phrases are added to each of the diagnosis, which pt becomes the higher priority?

  1. Pt with unstable BP and Angina
  2. Pt with stable vital sigh and MI
  • Answer: Pt with angina and unstable BP becomes the priority pt

4 rules for prioritization

  1. Acute beats Chronic
    • Meaning that an Acutely ill pt has higher priority than Chronically ill pts
    • For instance, among the following pts, a pt with COPD, CHF, or appendicitis, which one has the highest priority?
      • Pt with appendicitis (acute condition). Both COPD and CHF are chronic conditions

Fresh Post-op (12 hours) beats medical or other surgical

    • For instance, among the following pts, a pt 2-hour postcholecystectomy, a pt with COPD, and a pt with acute appendicitis, which pt has the highest priority?
      • The 2-hour postcholecystectomy is the highest priority pt … (Fresh post-op, <12 hours)
    • Pt with “radical neck dissection” is added to the above scenario?
      • The 2-hour postcholecystectomy is the highest priority pt
    • Pt with “bilateral above the knee amputation” is added to the above scenario?
      • The 2-hour postcholecystectomy is the highest priority pt
    • Pt with “right frontal craniotomy” is added to the above scenario?
      • The 2-hour postcholecystectomy is the highest priority pt

The point here is that surgery less than 12 hours takes precedence over medical and other surgical conditions

  1. Unstable beats Stable
    • This means that an Unstable pt has a higher priority over Stable pts

How to determine that a pt is stable or unstable?

Word description that makes a pt stable Word description that makes a pt unstable

    • Stable  Unstable
    • Chronic illness  Acute illness
    • Post-op greater than 12 hours  Post-op less than 12 hours
    • Local or regional anesthesia  General anesthesia in the first 12 hours
    • Lab abnormalities in the A or B level
      • Creatinine, BUN, Hemoglobin 8 to 11, Bicarb, elevated Hematocrit, elevated BNP, elevated Na level, RBCs off
    • Lab abnormalities in the C or D level
      • INR in the 4s, K in the 6s, pH in 6s, CO2 in the 50s, low O2 sat, high WBC, low ANC, low CD4, low Platelets

Word description that makes a pt stable Word description that makes a pt unstable

    • Ready for discharge, To be discharged, Admitted longer than 24 hours
    • Newly diagnosed, Newly admitted, Not ready for discharge, Admitted less than 24 hours
    • Unchanged assessment  Changing or changed assessment
    • Experiencing the typical expected S/Sx of the disease with which they were diagnosed
    • Experiencing unexpected S/Sx

Example

Which of the following pt is the highest priority?

  1. A 16-year-old female with meningococcal meningitis who has had a temp of 103.8 ºF since she was admitted 3 days ago
  2. 67-year-old male with IBS (irritable bowel syndrome) who spiked a temp of 103.4 ºF this afternoon

Answer: the 67-year-old pt has the highest priority

    • 16-year-old: Dx: meningococcal (acute)—high
      • Who has had (constant)—low
      • Temp of 103.8 (expected)—low
      • Admitted 3 days ago (>24 hours)—low
    • 67-year-old: Dx: Irritable bowel syndrome (chronic)—low
      • Temp spiked (changed)—high
      • This afternoon (acute)—high

Four things that always make you unstable, even if they are expected

    • Hemorrhage—(but not bleeding)
    • High fevers over 105 ºF—can lead to seizure
    • Hypoglycemia—can lead to brain damage
    • Pulseless or Breathless
      • Example, V-fib or asystole
      • Exception: At the scene of an unwitnessed accident pulseless and breathless pts are low priority because they are likely dead. Therefore, low priority

In a mass casualty incident, these 3 things result in a BLACK TAG

  1. Pulseless
  2. Breathless
  3. Fixed and dilated pupils (even they are still breathing)
    • Therefore, “Tag them black and ship them last”

Tie Breaker Rule

    • If the above 3 rules result in a tie breaker, use the following as a guide
    • The more vital the organ, the higher the priority
    • Use this rule with the organ of the modifying phrase and not the diagnosis
    1. Brain
    2. Lung
    3. Heart
    4. Liver
    5. Kidney
    6. Pancreas

Example

  1. You have a 23-year-old male with CHF (chronic—low) with K (6.6—high), and no EKG changes (constant—low)
    • Organ: Heart (potassium)
  2. Chronic Renal failure (chronic low) with a creatinine of 24.7 (expected—low), and pink, frothy sputum (unexpected—high)
    • Organ: Lung (frothy)
  3. Acute Hepatitis (acute—high) with jaundice (expected—low), increased ammonia (expected—low) who you cannot arouse (unexpected—high)
    • Organ: Brain (He Wins!)

Example

Determine whether the following are stable or unstable

    • Angina pectoris—stable
    • Angina pectoris with crushing sternal pain—stable, (expected)
    • Angina pectoris not relieved by rest—not stable

Delegation of Responsibility

Do not delegate the following responsibilities to an LPN. An LPN is not allowed to assume the following responsibilities … The LPN

  1. Cannot start an IV
  2. Cannot hang or mix IV meds
  3. Cannot push IV Push meds

LPN can only maintain an IV and document the flow

  1. Cannot administer blood or deal with Central lines … Including flush, change dressings
  2. Cannot make the care plan … They can however implement the care plan
  3. Cannot perform or develop teaching … They can reinforce teaching
  4. Cannot take care of unstable pts
  5. Cannot perform the “first” of anything … The first of anything is either making the care plan or assessment

For instance, the LPN

    • Can perform tube feeding only after the nurse did the first tube feeding
    • Can change post-op dressing only after the nurse change the first dressing
    • Should they change the first post-op dressing the day of surgery? No
    • Can feed stroke pt only after the nurse did the first feeding
    • Can ambulate post-op pt only after the nurse had first done so
    • Can take pt out of bed post-op only after the nurse had first done so
    • Can take a set of V/S post-op only after the nurse had first done so
  1. Is not allowed to assess: admission, d/c, transfer, or first assessment after a change.

Example

    • I think I heard new crackles on that guy in Room 52. Who should go assess this pt? … The RN or the LPN?
      • The RN must assess the pt since this is a new onset or change of a symptoms

Example

    • So who sould the RN check? And who should the LPN check?
  1. Angina with crushing substernal chest pain, 3 days ago, on nitro
  2. Subtotal thyroidectomy done 2 days ago and now states “why are they watching elephants?”
      • The RN should check the pt with subtotal thyroidectomy (onset of a new and worsening symptom, which may be thyroid storm)
      • The LPN should check pt with angina with crushing chest pain (expected)

Do not delegate the following responsibilities to a UAP

  1. Charting—UAP can chart what they did but they cannot chart about the pt. For example,
    • They can chart, “side rail is up, bed is lowered, etc.”
    • They cannot chart, “patient less anxious, tolerated ambulating well”
  2. Medication administration—They cannot administer medications unless medication is
    • Topical medications, over the counter (OTC) medications, and barrier creams
    • Cannot give Nitroglycerin or Neosporin ointments because nitroglycerin and Neosporin are not OTC
    • Can they give hydrocortisone cream? No
    • Can they give A&D ointment? Yes
  3. Assessments—Except vitals or Accu-Chek for diabetes
  4. Treatments—Except for enemas

The RN may delegate ADL (activity of daily living) tasks to a UAP … However, the UAP should never do any ADL task first

What to and not to delegate to the family members and friends of pts

    • Never delegate to the family safety responsibilities. For example, if a family member or friend of pt tells the RN
      • “Would you leave the restraints on my dad off and I’ll call you before I leave?”

The answer is: Do NOT delegate safety responsibility to family members or friends of pts

      • RN cannot delegate safety to a non-hospital caregiver unless the person is trained (seater) on how to do the tasks. The RN must document in the pt’s record what exactly was taught
      • Can the mother give insulin shot to her 3-year-old child? Yes, if you teach her and document teaching
      • What if a new mother asks the RN to “leave the railing of my baby’s crib down and I will put it back up after finish bathing my baby. You can go about what your business”

The RN’s answer should be something similar to that. “Don’t worry about me leaving, I

will stay with you to make until you are done.”

The point is to make sure the rail is put back up before you leave the room

Staff Management

How do you intervene with inappropriate behavior from staff?

This is not prioritizing, this is not delegating … this is handling staff members who did stupid things

There are always 4 answers

  1. Tell Supervisor
  2. Confront them and take over the task the staff is implementing immediately
  3. Talk to them later
  4. Ignore it

Never ignore inappropriate behaviors … So, “ignore it” is the wrong answer

    • Use the incident as an opportunity to teach and change behavior

Choosing among the remaining 3 options depends on the nature of the incident … Therefore, ask yourself one of the following?

    • Is the staff doing something Illegal?
      • If answer is YES … Then, Tell Supervisor
    • If what the staff is doing is not illegal?
      • Then ask yourself if anyone (patient, the co-worker, or other staff member) is in immediate of physical or psychological harm?
      • If answer is YES … Confront immediately and take over
    • If no one is in harm’s way, ask yourself if this behavior is simply inappropriate
      • If so, talk to that particular staff at a later time about the incident

Examples

  1. You suspect the RN is diverting narcotics. Tell Supervisor
  2. The Aide is giving perineal care to pt, not wearing gloves? Confront and take over the task
  3. The RN is going home with bulging pockets? Tell Supervisor
  4. You notice surgeon contaminates her gloves? Confront
  5. The RN always gives report, always says exasperation instead of exacerbation …

Talk to them later

If an illegal act can be harmful to the pt … first, takeover the task and then report the incident to supervisor

Questions

What if you find 2 pts involving in sexual intercourse? What is best thing to do?

    • Shut the door and give then privacy
    • As a staff, you do the same if you stumble upon a pt masturbating in his or her room

Organ Location

If a question is asking you to identify a named organ on a picture on the screen, it is a simple point-and-click on the organ on the screen … To do so, move the mouse over the area and click

    • An “X” identifies the organ you want to select as your answer
    • As long as you are in the general vicinity, you will identify the organ, given you are correct

Note

  • Not present on both pictures are the brain, lungs and kidneys
  • Questions regarding the brain will be more on identifying the lobes with relation to their functions

Auscultation Over Heart Valves

When answering questions to identify heart valves, you must click exactly over a narrow area as to mimic stethoscope placement. The areas auscultated for murmurs (or sounds) are remembered by “A PET M”

    • The Aortic valve is located in the 2nd intercostal space, right of the sternal border
    • The Pulmonic valve is located in the 2nd intercostal space, left of the sternal border
    • The Erb point is rarely asked on the exam
      • It is located in the 3rd intercostal space, left of the sternal border
      • Erb point is between the pulmonic and the tricuspid valve
    • The Tricuspid valve is located in the 4th intercostal space, left of the sternal border
    • The Mitral valve is located in the 5th intercostal space at the midclavicular line
      • The apical pulse is in the same location as the mitral valve auscultation

Palpating for Pulses

Know where on the body these pulses are located

    • For instance, anticipate questions about identifying the popliteal pulse on a picture on the human body

Guessing Strategies

Everybody taking this exam will guess at some point. Instead of guessing blindly, here are some strategies that can help you answer questions correctly

Use these approaches when all the answers do not make sense …

  1. In psych nursing
    • Pick, “I will examine my feelings”
      • This is to prevent countertransference
      • Countertransference: A pt reminds a nurse of her dad, who she a bad relation with, so she interacts in a hostile manner with the pt
    • Or pick, “Establish a trust relationship”
  2. Nutrition
    • When all else fails, go with “baked”—not fried—but “backed chicken”
      • If there is no chicken, pick fish—not shellfish (lobsters, crabs, or shrimp). Shellfish is high in cholesterol
    • Never pick casseroles for children—they won’t eat it
      • A casserole is any kind of stew or side dish that is cooked slowly in an oven
    • Don’t mix meds in kids food
      • Always ask pts for permission before you mix their food and medication together
    • For toddlers, pick “finger food”
      • Examples are: Hot dogs, tofu, French fries
      • Your answer should focus on what can they eat on the run
    • For preschoolers, “leave them alone”
      • One meal a day is ok
      • Growth curve around preschool year plateaus … Toddlers growth curve goes up
  3. Pharmacology
    • Memorize S/E
    • Don’t memorize dosage, route
    • If you know what a drug does but don’t know the S/E, how do you proceed? … Pick the “S/E in the same body system the drug is working”
      • For instance, if you have a GI drug, and drowsiness, tachycardia, and diarrhea are part of the answer choices. What S/E will you pick? Pick “diarrhea”
      • From the same above list … For cardiac drug, pick “tachycardia”
      • For CNS drug, pick “drowsiness”
      • If you have no idea what the drug is … and the drug is PO, pick a GI side-effect
    • Never tell a child a “medication is candy”
      • The child may give grandma’s valium to other children thinking the pill is candy
  4. OB: check “fetal heart rate”
  5. Med/Surge
    • What is the first thing to assess? “Check for LOC (level of consciousness)”—not airway
      • Think about a code or you find a pt on the floor … LOC is always checked first
      • “Sir, Sir, Sir! Are you ok? Can you hear me?” If there is no response, A-B-C is then done next
    • What is the first thing to do? “Establish an airway”
  6. Pediatrics
    • For growth and development, you can always narrow down your answer to three rules, which goes along “giving the child more time”
      • Rule #1: When in doubt, “call it normal” … Example: Some six year olds can read. Some can and some can’t. Pick the answer that says, “Give the child more time” … There is no doubt that a 13-year-old who not potty-trained is normal
      • Rule #2: When in doubt, pick the “older age” in the 2 that it could be … In what age can the child walk? Both 12 months and 14 months are right … Pick 14 months. In that case, you give the child more time
      • Rule #3: When in doubt, pick the “easier task” … At 6 months, a baby can roll over or sit with support … Pick “roll over” as your answer because it is the easier task.
    • In growth and development, there are always two correct answers. The mantra is to give the child more time … Chant in your head: “NORMAL, OLDER, EASIER”
  7. General guessing skills
    • “Rule out absolutes” … That is if you are guessing. However, it is commonly known to never push potassium
    • Avoid answer choices that say the same thing … Neither one is correct. For instance, the following 2 answer choices are the same. Answer choice #1: Increased bowel sounds … Answer choice #2: borborygmi. Pick a different one
    • If two answers are opposite, one is probably correct
    • Umbrella strategy … Find more than one correct answer? Find the global answer. Ex: Use safety and good body mechanics if possible
  8. Prioritization of pt needs
    • Pt is need with the worst outcome has the highest priority—in other words, pick the Worst Consequences Game
      • For example: Which is highest priority for suicidal patient? (a) Don’t give tranquilizer. (b)

Don’t orient to unit? (c) Don’t put him on suicide precautions? And (d) Don’t introduce him to staff?

To answer this question, ask yourself is: “What would happen if I did not implement the task?” Answers: (a) Agitated, (b) Lost, (c) DEAD, (d) Doesn’t know anyone. The worse case scenario is (c). The pt would be DEAD. Answer choice (c) is the answer.

  1. When you’re stuck between two answers … Go back and read question. You probably missed something
  2. The Sesame Street Rule

  • When nothing else works, look at all the answer choices to see which one looks different from the others
    • Looking at the picture below, one is not like the others … If that happens on the exam, the answer choice that looks different is likely the right answer
    • The wrong answers look the same
  1. Don’t be tempted to answer based on ignorance rather than knowledge
  • If you don’t know drug, pull it out of the question and try to answer based on fundamental knowledge or common sense

o For example: The Piggyback question about Amikacin … You don’t know the medication Amikacin, but you do know that piggybacks need a pump. Don’t analyze those first 10 questions on the NCLEX. USE COMMON SENSE

  1. The are 3 expectations you are not allowed to have

  • Expectation #1: Remember—the test will not be what you expect
    • Don’t expect 75 (RN) or 85 (LPN) questions … Go to the exam center and expect 265 or 285 questions
    • Prepare yourself to go for the maximum
    • If you freak OUT when you get to 76 (RN) or 86 (LPN) and on, it might impact your performance on the exam … Negativity will kill you
    • This is a computer-adapted test—if you get to 200 you’re not failing … You’re still in the game!
  • Expectation #2: Don’t expect to know everything. It ain’t happening
  • Expectation #3: Don’t expect a perfect day
    • Perfect parking spot
    • Perfect Seat Partner
    • You stuck it out through nursing school this far … You have perseverance and strength of character
    • Get through one question at a time

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