Mark Klimek

Lectures Notes
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LECTURE 1
Acid Base Disorders
└ ✰ YOU SHOULD KNOW THIS TO PASS ✰

How to identify the type of acid/base disorders

1. You should know the normal values for pH, CO2, and HCO3 (bicarbonate) to solve acid/base
questions!

● Normal pH = 7.35 ~ 7.45

● Normal CO2 = 35 ~ 45
● Normal HCO3 = 22~26.

2. Then, you should look at pH value to decide if it’s acidotic or alkalotic

● If pH is < 7.35, the acid base imbalance is acidotic
● If pH is > 7.45, the acid base imbalance is alkalotic

3. Then, you should determine if the imbalance is metabolic or respiratory by looking at whether
bicarb (HCO3) goes the same or opposite direction with pH
● Use the “Rule of Bs”: if pH and Bicarb, Both moves the same direction, it’s metaBolic
imbalance … if opposite direction it’s respiratory

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☁ Questions ☁
Q1. pH = 7.3, HCO3 = 20?

● pH (down) acidotic, HCO3 (down) = Both = metaBolic

● Therefore, metabolic acidosis

Q2. pH = 7.58, HCO3 = 32?

● pH (up) alkalotic, HCO3 (up) = Both = metaBolic
● Therefore, metabolic alkalosis

Q3. pH = 7.22, HCO3 = 35?

● pH (down) acidotic, HCO3 (up) = opposite = respiratory
● Therefore, respiratory acidosis

Q4. pH = 7.50, HCO3 = 25?

● pH (up) alkalotic, HCO3 (normal) = not the same direction = respiratory
● Therefore, respiratory alkalosis

✴ NCLEX Tips ✴
● ✪ Boards doesn’t question you about mixed/complicated questions ☺

Signs and Symptoms of Acid/Base Imbalances

● Remember, “as the pH goes, so goes my patient, except for potassium” … that means:
○ If pH is low, everything is low, but potassium is high
○ If pH is high, everything is high, but potassium is low
● If pH goes over 7.45 = alkalosis
○ pH is high so everything is high except K+
○ High: tachycardia, tachypnea, HTN, seizures, irritability, spastic, diarrhea, borborygmi
(increased bowel sounds), hyperreflexia (3+, 4+)
○ K+: Hypokalemia
○ Main nursing intervention: suction for seizures
● If pH goes below 7.35 = acidosis
○ pH is low so everything is low except K+
○ Low: bradycardia, constipation, absent bowel sounds, flaccid, obtunded = lethargy,
coma, hyporeflexia (0, 1+), bradypnea, low BP
○ K+: hyperkalemia
○ Main nursing intervention: ambu bag/ intubation and ventilation for resp arrest
● ✧ Remember, “MAC Kussmaul” is the only acid-base imbalance that cause Metabolic
ACidosis with Kussmaul respiration (deep and laboured breathing pattern) !

☁ Questions ☁
Q. Signs and symptoms of respiratory acidosis? Select All That Apply.
[ +1 reflex, diarrhea, adynamic ileus, spasm, urinary retention, paroxysmal (sudden
outburst of emotion), atrial tachycardia, second degree Mobitz type 2, heart block,
hypokalemia ]

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● Acidosis means pH is low = so the pt goes LOW but K+ goes Up = low s&s +
hyperkalemia
● Answers: +1 reflex, adynamic ileus, urinary retention, second degree Mobitz type
2 heart block

Causes of Acid/Base Imbalance

└ Don’t get messed up with the causes and the signs & symptoms!
1) If it is lung, it’s respiratory, ask yourself, “are they over-ventilating or under-ventilating?”
● If UNDER ventilating, then pick ACIDOSIS = pH is < 7.35 (if it’s under, pH is also under)
● If OVER ventilating, then pick ALKALOSIS = pH is > 7.45 (if it’s over, pH is also over)

☁ Questions ☁
Q. What type of acid-base derangement is present in the following condition?
○ In labor? Over-ventilating = pH goes UP = Respiratory alkalosis
○ When drowning? Under-ventilating = pH goes DOWN = Respiratory acidosis
○ For Patient with a PCA (patient-controlled anesthesia) pump?
Under-ventilating = pH goes DOWN = Respiratory acidosis

2) But, if it is not lung, it’s metabolic.

● If the patient has prolonged gastric vomiting or suction (= sucking out acid), pick
metabolic alkalosis
● For everything else that is NOT lung, pick metabolic acidosis

✴ NCLEX Tips ✴
● If you don’t know the answer, your default setting is “Metabolic Acidosis”
● Always pay attention to modifying phrase rather than original noun/ diagnosis

Ventilators
Ventilators?
● 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 insu ciently to breathe. A
ventilator is equipped with a high and a low-pressure alarm
High Pressure Alarm
● Triggered by increased resistance to airflow → Look for obstruction
○ Kinks in tubing → unkink it
○ Condensed water in the dependent tube → empty the water
○ Mucus plugs → make pt to turn, cough, deep breath, and ultimately suction PRN

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☁ Questions ☁
Q. What is the appropriate order to address a high pressure alarm in a mechanical
ventilator?
● 1) unkink 2) empty water out of the tubing 3) turn pt, ask pt to cough or deeply
breathe 4) suction

Low Pressure Alarm

● Triggered by decreased resistance to air flow → Look for disconnection
○ Main tube disconnection → reconnect unless tube is on the floor
○ O2 sensor tube disconnection → reconnect unless tube is on the floor
● The ventilator may be set too high or too low
○ When setting is too high, pt is OVER-ventilated: Respiratory Alkalosis (panting)
○ When setting is too low, pt is UNDER-ventilated: Respiratory acidosis (retaining CO2)

☁ Questions ☁
Q. The physician wants to wean the patient o the ventilator in the morning. At
6am, the ABGs said respiratory acidosis. What would you do next?
● Respiratory acidosis = pH is low = pt is low = UNDER ventilating = can’t wean o
ventilator yet
● Therefore, RN notifies the physician that the pt is not ready to be weaned o the
ventilator
● Patient is ready to be weaned o if patient is OVER-ventilated = respiratory
alkalosis

LECTURE 2

Alcoholism and Psychological Problems

Denial of any abuse
● The #1 psych problem is DENIAL of any abuse (i.e., child abuse, gambling, drug abuse,
spousal abuse, elder abuse… etc)
● How to respond/treat patients with denial? CONFRONT them by pointing out the di erence
between what they say and what they do. This is NOT an aggression. Don’t attack the patient.
● E.g., “you say you are not an alcoholic but it is 10 am and you’ve already had 6 packs”
● Good answer has “I” while bad answer has “YOU”
● Exception: only time denial is okay is for loss and grief – stages of grief are “DABDA” – denial,
anger, bargaining, depression, acceptance
● So, when the question is about patient in denial, pay attention to whether you are dealing
with loss or abusive

✰ Loss → support
✰ abuse → confront

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Dependency vs. Codependency

● The #2 psych problem is DEPENDENCY or CODEPENDENCY
● Dependency: when they get the significant other to do things or make decisions for them
○ The abuser is dependent
● Codependency: 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 codependency have a symbiotic, yet a pathological relationship
○ The dependent patient gets a free ride on the co-dependent
○ The co-dependent patient feels good from “doing stu ” for the abuser
● How do you treat dependency/codependency?
○ Dependent patients are “abusers” → confront them
○ Co-dependent patients have self-esteem issues → teach patients 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 codependent person to do things or
make decisions
○ If what the significant other is being asked to do something inherently dangerous and
harmful, then this is manipulation
● How do you treat manipulation? Set LIMITS and ENFORCE them

☁ Questions ☁
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
○ Manipulation … there is 1 patient – no self-esteem issues
○ Easier to treat because no one likes to be manipulated
● 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 is a dependency/codependency situation
○ Dependency … there are 2 patients
○ The dependent has a denial issue
○ The co-dependent has a self-esteem issue

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Wernicke (Korsakoff) Syndrome

Wernicke
● Typically, Wernicke and Korsako are 2 separate disorders. The NCLEX however bundles
these two situations as one condition
o Wernicke is an encephalopathy
o Korsako is a psychosis
o Wernicke and Korsako tend to do together
● Psychosis induced by vitamin B1, thiamine deficiency
● This is a situation the patient loses touch with reality due to vitamin B1 deficiency
● The primary S/Sx are amnesia (memory loss) and confabulation (making up stories)
● Confabulation – the lies for these patients are just a s real as reality

☁ Questions ☁
Q. How do you deal with a patient with Wernicke and Korsako who is
confabulating about going to a meeting with Barack Obama this morning?
● Redirect the patient to something he can do
● For example, tell patient something along that line: “why can we go watch TV to
see what is on the news today”

Characteristics of Wernicke and Korsakoff syndrome

1. Preventable → take B1
2. Arrestable (stop it from getting worse) → take B1
3. Irreversible (70%) → will kill brain cells

Antabuse (Disulfiram)
● Antabuse (Disulfiram) – alcohol deterrent; alcohol relapse prevention
● 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 e ect
o Works in therapy better than in reality
● Onset (how long it takes to start working) and duration (how long it lasts) of e ectiveness of
Antabuse/Revia is 2 weeks
o For instance, if pt will be at a function and would like to drink, the patient must be on
Antabuse/Revia at least 2 weeks prior to the event
● Patient teaching
o Teach patients to avoid all forms of EtOH. Not doing so may lead to symptoms of
N/V, even death
o Teach them to avoid the following items as they contain alcohol (e.g., mouthwash,
cologne, perfume, aftershave, elixir, most OTC liquid meds, insect repellant, hand
sanitizer, vanilla extract (can’t have cupcake with unbaked icing))
o On the exam, DO NOT pick Red Wine Vinaigrettes which DOES NOT have alcohol in it

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Overdose and Withdrawal

1. First thing you ask in overdose question: Is it an UPPER or a DOWNER?
o This is because every abuse drug is either an upper or a downer
o However, laxative abuse in the elderly is neither an upper or a downer
Upper Downer
● Ca eine ● There are over 135 drugs that are
● Cocaine downers
● PCP/LSD (psychedelics/ hallucinogens) ● If it’s not an upper, it’s a downer
● Methamphetamines
● Adderall
Memorize these five for the NCLEX
Signs and symptoms Signs and symptoms
● Things go UP! ● Things go DOWN!
● Euphoria, seizures, restlessness, ● Lethargic, respiratory
irritability, hyperreflexia (3+,4+), depression/arrest, constipated, etc
tachycardia, increased bowels
(borborygmi), diarrhea
● What is the highest nursing priority to anticipate in an UPPER or a DOWNER?
o UPPER: suctioning due to seizures
o DOWNER: intubation/ventilation due to respiratory arrest

☁ Questions ☁
Q. One of your patients is “high on cocaine”. What is critically important to assess?
● Having a RR of 12 is NOT a critical measurement to assess for that patient
● However, assessing for reflexes (3+, 4+), irritability, borborygmi, or increased
temperature would be more appropriate
● The ABC rule does not apply here. The patient’s ABC in cocaine toxicity is
unremarkable

2. After you know that the drug is either upper/downer, you should ask whether it is an
OVERDOSE or a WITHDRAWAL
o Overdose and withdrawal have the opposite e ects
Upper (+) Downer (-)
Overdose (+) TOO MUCH (+) TOO LITTLE (-)
Withdrawal (-) TOO LITTLE (-) TOO MUCH (+)

✴ NCLEX Tips ✴
● Use the rule of multiplication – if the signs are the same the results are positive, if
signs are di erent the result is negative

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☁ Questions ☁
Q. The driver of a squad car calls the ER and says he is bringing a patient who is
Oded on cocaine. What do you expect to see? SATA.
● Overdose (+) of upper (+) medication = “too much”
● S/Sx: irritability, +4,+3 reflexes, borborygmi, increased temp, etc.

Q. Example: the same patient is now withdrawing from cocaine.

● Withdrawal (-) of upper (+) medication = “too little”
● S/Sx: respiratory rate < 12, di cult to arouse → RN should give Narcan

Drug abuse in the Newborn

● Always assume intoxication (+), at birth, in a newborn less than 24 hrs after birth.
● 24 hrs or more after birth, you should assume the newborn is in withdrawal (-)

☁ Questions ☁
Q. You are caring for an infant born to a Quaalude addicted mother 24 hrs after
birth. SATA.
● Withdrawal (24h after birth) of downer (Quaalude) → TOO MUCH
● S/Sx: di cult to console, seizure risk, shrill, high pitched cry, exaggerated startle
reflex

Alcohol Withdrawal Syndrome (AWS) vs. Delirium Tremens (DT)

● Alcohol withdrawal syndrome and delirium are di erent
● Every alcoholic goes through AWS approximately 24 hrs after the person stops drinking
● But, less than 20% of alcoholics in AWS progress to DT
● DT occurs about 72 hrs after the person stops drinking
● AWS always precedes DT; but DT does not always follow AWS

AWS (withdrawal of downer = too much) DT (withdrawal of downer = too much)

● Occurs after 24 hrs after drinking ● Occurs after 72 hrs after drinking
● Non-life threatening to self and others ● Life threatening to self and others
Nursing care plan Nursing care plan
● Regular diet ● NPO or clear liquid diet (d/t seizure risk)
● Semi-private room, anywhere on the ● Private room, near nursing station
unit ● Restricted bed rest (pt is not free to
● Pt is up ad lib (= free to move around as move around as desired, no bathroom)
desired) ● Restraints (vest or 2-point lock letters)
● No restraints

NOTE
● 2-point lock letters restraints: restraints in one upper and the contralateral lower extremities;
release and secure upper arm first and then release and secure the foot; switch extremities
q2hrs

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● For both AWS and DT, give anti-hypertensive meds, tranquilizer, multivitamin with vit B1 ;
alcohol withdrawal means withdrawal of downer = too much; so BP will be too high and mood
will be too high and there is risk for Wernicke’s which can be prevented/slowed with Vit B1

☁ Questions ☁
Q. So, what two situations would respiratory arrest (-) be a priority?
● Overdose of a downer, withdrawal of an upper
Q. Question: which pts would seizure (+) be a risk for?
● Overdose of an upper, withdrawal of a downer

Aminoglycosides (Top 5 most tested drugs)

What is Aminoglycosides
● Aminoglycosides are the big guns of Abx – use them when nothing else works!
● But, aminoglycosides are unsafe at toxic levels and “safety” then becomes an issue; one of
the top 5 drugs that are most frequently tested on the NCLEX
○ Top 5 drugs: psychiatric, insulin, anticoagulant, digitalis, aminoglycosides
○ Other drugs: steroids, BB, CCB, pain meds, OB meds
● “A Mean Old Mysin” = Aminoglycosides
○ Meaning. It would be used to treat serious, resistant, life-threatening, gram negative
infections; ”A mean old mysin” will treat a mean old infection
○ E.g., TB, septic peritonitis, fulminating pyelonephritis, septic shock, infection from 3rd
degree wound covering > 80% of the body
○ BUT, sinusitis, otitis media, bladder infection, viral pharyngitis, strep throat are NOT
THE OLD MEAN infections and are not treated with aminoglycosides
● Aminoglycosides ends with “Mysin”
○ Gentamicin, Vancomycin, clindamycin, streptomycin, Cleomycin, Tobramycin
○ BUT, THROW o “thro-mycin” lists from aminoglycosides: azithromycin,
clarithromycin, erythromycin
● Toxic e ects? – think of a mouse's ear shape (ear, kidneys)
○ Ear; ototoxicity – hearing (#1), balance, tinnitus (ringing of the ear, CN8 toxicity)
○ Kidneys; nephrotoxicity (monitor Cr level)

✴ NCLEX Tips ✴
● For Creatinine level, choose 24hrs Cr clearance level over serum creatinine for
questions

Route of aminoglycosides
● Aminoglycosides are NEVER given PO since they are NOT absorbed, which means they would
not have any systemic e ects if given orally
● BUT there are 2 exceptional cases when you give aminoglycosides PO,
o Hepatic encephalopathy (hepatic coma): ammonia level is too high (e.g., E.coli = #1
producer of ammonia which can lead to encephalopathy at toxic level)
o Pre-op bowel surgery
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o Aminoglycosides abx is given PO and it stays in the gut (not absorbed) and sterilize
the bowel – in this case it’s not toxic
o “Who can sterilize my bowl? NEO KAN”; neomycin and kanamycin are PO
aminoglycosides used for bowel sterilizer
● Otherwise, aminoglycosides is given IM or IV since it’s excreted in feces and not absorbed in
the GI tract

Troughs and Peaks

What are Troughs and Peaks
● Troughs: when drug is at their lowest concentration in the pt’s blood
● Peaks: when drug is at their highest concentration in the pt’s blood
● Trough and peak levels are drawn before and after the administration when dealing with
narrow therapeutic window/index meds
● “TAP” – Trough → Administer → Peak
● Narrow therapeutic window/index means that there is a small di erence in what works and
what kills. Therefore close monitoring of drug concentration level in pt’s blood is required
● Drugs with TAP: aminoglycosides, digoxin

☁ Questions ☁
Q. Which one of the following meds would “trough and peak” be important? lasix or
digitalis
● Lasix (furosemide) – smaller dose 5~10, larger dose 80~120
● Digitalis (Digoxin) – smaller dose 0.125, larger dose 0.25
● dIgoxin requires to draw trough and peak levels due to narrow therapeutic
window

When do you draw a Trough and a Peak?

● For trough, always draw 30 mins before next dose (no matter what meds/what routes)
● For peak, it depends on the route (NOT meds)
○ SL: 5~10 mins after drug is dissolved
○ IV: 15~30 mins after drug is finished (bag is empty)
○ IM: 30~60 mins
○ SQ: depends on insulin (see diabetes lecture)
○ PO: not necessary, not tested

☁ Questions ☁
Q. you give 100 mL of a drug at 200 mL/ hr. If you hang the drug at 10 am, it will
finish running at 1030 am. When will the drug peak? 1) 10:15, 2) 10:30, 3) 10:45, 4)
11:00
● Peak for IV drug is 15~30 mins after bag is empty = 1045~1100
● So, the answer is technically both 3 and 4
● For NCLEX if you have to choose only one, go with the highest time without
going over, so 4 is better answer

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LECTURE 3

Calcium Channel Blockers

What is CCB?
● CCBs are like “valium” for your heart
○ Valium calms you down in your body. Therefore, CCB relaxes and slows down the heart.
■ If heart is tachy, tachyarrhythmia, heart attack → needs to be rested → GIVE CCB
■ If you are in shock, you are in heart block → needs to be stimulated → should NOT
give CCB
○ In other words, CCBs have negative inotropic, chronotropic, dromotropic e ects to heart
■ Negative inotropic: weaken/decrease the force of myocardial contraction
■ Negative chronotropic: decrease rate of impulse formation at SA node → decelerate
HR
■ Negative dromotropic: decrease speed that impulses from SA node travel to AV node
(decrease conduction velocity)
○ Positive ino/chrono/dromotropic = cardiac stimulants = strong heartbeat
○ Negative ino/chrono/dromotropic = cardiac depressants = weaken/slow down/ depress
heartbeat = CCB

What do CCB treat? = “A, AA, AAA”

○ A: Antihypertensives – relaxes heart BV → BP goes down
○ AA: AntiAnginal – relaxes heart, works by decreases oxygen demand
○ AAA: AntiAtrialArythmia – treats atrial-flutter/fibrillation, premature atrial contraction, atrial
bigeminy, SVT

Side effects of CCB: “H-H”

○ Headache – vasodilation→migraine (for SATA questions, H/A often is right)
○ Hypotension – as it relaxes BV

● Examples of CCB: -ZEM, -DIPINE, verapamil/isoptin, Cardizem (diltiazem)

○ Cardizem can be given with IV drip
● Nurse should assess/monitor BP before giving CCB
○ If SBP is < 100, hold the CCB
○ If SBP is < 100 when Cardizem (diltiazem) is given with drip, titrate the rate of the IV
depending on how low the SBP is

Rhythm strips that you MUST know

First know these keywords
● Tachycardia = “bizarre”
● Fibrillation = “chaotic”
● P wave = “atrial”
● QRS depolarization = “ventricular”

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1. Normal sinus – P, QRS, T waves for every single complex, QRS complex are equally spaced

2. VFIB – “chaotic” QRS complexes, NO pattern

3. V tach – “bizarre”, wide QRS complexes, there is a pattern,

4. Asystole – a flat line, “lack of QRS complex”

5. Atrial flutter – rapid P wave depolarization, flutter is always “saw tooth” like

6. Atrial fibrillation – “charotic” P wave patterns

7. Premature ventricular contractions (PVC) – “periodic” wide, bizarre QRS’s, low priority
o Low priority usually; PVCs after an MI is common and it’s also a low priority
o Elevate to moderate priority if: 6 consecutive PVCs in a min, more than 6 PVCs in a row, R on
T phenomenon (= PVC falls on a T wave)
o Never high priority

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Lethal rhythms (high priority)

● V-FIB and ASYSTOLE
o LOW to NO cardiac output → no brain perfusion → confusion/ death in 8 mins

☁ Questions ☁
Q. Vtach, Afib, Aflutter – what is potentially life threatening?
● V-tach (it becomes lethal without pulse/cardiac output)
● V-tach (there is cardiac output) vs. Vfib (no cardiac output)

Cardiac output (CO)?

● Without CO: no pulse
● With CO: pulse presents

Again,
● Whenever question says QRS Depolarization = it’s talking about ventricular
● If it says P wave depolarization = it’s talking about atrial

Treatments for dysrhythmias

Ventricular Atrial Lethal
PVCs V-tach Supraventricular V-fib Asystole
(ventricular) (ventricular) Arrhythmia or
(atrial) pulseless
v-tach
● Lidocaine “ABCD” ● Defib ● Epinephrine
● amiodarone ● Adenosine (=shock) (first)
● Beta-blockers (lol) ● Atropine
● CCBs (second)
● Digoxin, Lanoxin

Atrial treatments = “ABCD”

● Adenocard/adenosine (*needs to be IV pushed less than 8 seconds and flush 20 cc with NS →
this will put pt in asystole for 30 seconds → don’t worry, it will come out)
● Beta-blocker (-lol) – they are like valium that treat A, AA, AAA; have negative
ino/chrono/dromotropic e ects on the heart just like CCB; same side e ects as CCBs “H-H”
● CCB – they are like valium that treat A,AA,AAA (only better than BB for pt with asthma/COPD)
o BB and CCB are similar in e ects, only di erence is BB is bad for ppl with asthma/COPD as
it bronchoconstricts (CCB is used for pts with respiratory bronchoconstriction)
● Digitalis/Digoxin, Lanoxin – know all these names

Note
● When dealing with an IV push drug if you don’t know go slow, except adenosine

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CHEST TUBE
Purpose of chest tube?
● The purpose of C-tube: to re-establish NEGATIVE pressure in the pleural space (negative
pressure makes things stick together in the pleural space so that the lungs expand when the
chest wall moves)
○ Pleural space is where Neg pressure is good (negative makes things stick together,
positive pressure pushes things away)
● chest wall vs. lungs – in the lungs, there are alveoli
○ Alveoli < lung < visceral pleura lining < pleural cavity (space) < parietal pleura lining <
chest wall
○ In the normal lungs, negative pressure is in place at the pleural space (stick together and
ensure lungs expand in accordance with the chest wall’s rise and falls)
○ In abnormal lungs where things (air, blood) are in the pleural space, positive pressure is
there (push the chest wall from lungs) << so negative pressure needs to be established by
placing chest tube and removing those obstacles

● In a pneumothorax, C-tube removes AIR

○ As pneumothorax has positive pressure due to air, C-tube is placed to remove the air to
re-establish the negative pressure
● In a hemothorax, C-tube removes BLOOD
○ As hemothorax has positive pressure due to blood accumulation in the pleural space
● For pneumohemothorax, the chest tubes remove air and blood
○ Pleural e usion = fluid between pleural space)

☁ Questions ☁
Q1. Question #1. A chest tube is placed in a pt for a hemothorax (blood). What would
you report to a physician?
a) Chest tube is not bubbling
b) Chest tube drains 800 ml in the first 10 hrs
c) Chest tube is not draining
d) Chest tube is intermittently bubbling

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● Answer: c (draining is expected for hemothorax due to blood)

Q2. Question #2. A chest tube is placed in a pt for a pneumothorax (air). What would
you report to a physician?
a) Chest tube is not bubbling
b) Chest tube drains 800 ml in the first 10 hrs
c) Chest tube is not draining
d) Chest tube is intermittently bubbling
● Answer: a (bubbling is expected for pneumothorax due to air, the second
answer is b – as blood of 800 ml in 10 hrs is too much for pneumothorax)

Monitoring chest tube

● What will the bubbling, fluid output, blood output look like?
○ For hemothorax with chest tube, expect bubbling to not occur, blood output to occur
○ For pneumothorax with chest tube, expect bubbling to occur, blood fluid output to not occur

Location of chest tubes

● Apical (UP) for AIR (as air rises) – for pneumothorax
● Basilar (BOTTOM) for BLOOD (as blood gravitates to bottom) – for hemothorax

☁ Questions ☁
Q. Are these statements expected (last person to be seen) or not expected (first to
report to MD)?
● An apical chest tube is draining 300 mL the first hour
o Apical = Air = bubbling is expected → therefore, it’s bad
● A basilar chest tube is draining 200 mL the first hour
o Basilar = Bottom = Blood = draining is expected → therefore, it’s
expected
● An apical chest tube is not bubbling
o Apical = Air = bubbling is expected → therefore, it’s expected
● A basilar chest tube is not bubbling
o Basilar = Blood draining is expected → therefore, it’s not expected

☁ Questions ☁
Q1. Pt presents with a unilateral hemopneumothorax, how to care for this pt?
● Unilateral = one sided, hemo pneumo = both blood and air removal
● Place apical (pneumo) and basilar(hemo) chest tubes on the a ected side of
the lungs

Q2. Where are chest tubes placed for bilateral pneumothorax?

● needs apical chest tube one on the right top side and another one on the left
top side

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Q3. Pt presents with a unilateral hemopneumothorax. How do you care for this
patient?
● Place an apical and a basilar chest tube on the a ected side
● Note: always assume post trauma or postsurgical patients need unilateral chest
tubes unless otherwise specified

Q4. Where would you place a chest tube for a post-op right pneumonectomy??
● Post op 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) or wedge
resection

Closed chest drainage devices

● Types: Jackson-Pratt, Emission, Pneumovac, Hemovac, etc.
● What happens if one of those drainage devices is knocked over?
o Ask pt to take a deep breath and set the device back up
o It’s NOT a medical emergency. Don’t need to call the physician

If the water seal of the chest tube breaks:

1. Clamp (clamp the tube for less than 15 secs to prevent air to get into the chest)
2. Cut (cut the tube away)
3. Submerge (stick the end of the tube under sterile water)
4. Unclamp (unclamp the tube if it is still clamped; clamping prevents air to get into the chest,
but it does not allow things from the chest to get out so, clamping shouldn’t be longer than 15
secs)
● ✧ Note: clamp, unclamp, and placing the tube under water must be done in 15 secs

☁ Questions ☁
Q. The water seal chamber of the chest tube for a pt with a pneumo/hemo thorax
breaks. What is the FIRST thing to do as a nurse?
a) Clamp the tube
b) Cut the tube away
c) Submerge the end of the tube under sterile water
d) Unclamp the tube if it was initially clamped

● a) clamp
Q. The water seal chamber of the chest tube for a pt with a pneumo/hemo thorax
breaks. What is the PRIORITY/BEST thing to do as a nurse?
a) Clamp the tube
b) Cut the tube away
c) Submerge the end of the tube under sterile water
d) Unclamp the tube if it was initially clamped

● c) submerge into the sterile water; this solves the problem by re-establishing the
water seal

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Priority vs First actions

☁ Questions ☁
Q1. You notice on the monitor that a pt has a v-fib. Pt is unresponsive and there is
no pulse. What is the FIRST step in the management of this patient?
a) Place a backboard under pt’s back while pt is supine
b) Start the chest compression
● a) putting the backboards is first thing to do
Q2. You notice on the monitor that a pt has a v-fib. Pt is unresponsive and there is
no pulse. What is the PRIORITY/BEST step in the management of this patient?
a) Place a backboard under pt’s back while pt is supine
b) Start the chest compression
● b) starting the chest compression is the priority action

If a chest tube gets pulled out

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

Bubbling of chest tube

● can be good or bad depending on where and when
Where Water seal chamber Suction control chamber
When Intermittent Continuous Intermittent Continuous
Good Bad Bad Good
Document it Indicates Indicates that Document it
break/ leak in suction pressure is
the system → too low → increase
find it and the suction
tape it pressure until it is
continuous
● “In the seal, continuous is bad”

Analogies
● Intermittent: A straight (in and out) catheter = thoracentesis
● Continuous: foley catheter = chest tube
● Higher risk of infection from foley catheter and chest tube

Rules for clamping tubes

● Do not clamp a tube for more than 15 secs without MD’s order
● Use rubber tooth (that does not puncture tubing), double clamps
● So, nurse has no more than 15 secs to clamp, cut, submerge, and unclamp when water seal
breaks

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Congenital heart defects (CHDs)

● It either makes a lot of “trouble” or “no trouble”, nothing in between
● “TRouBLe” (lower case for vowels)

Pediatric pts with “TRouBLe” CHDs Pediatric pts with “No trouble” CHDs
● Need sx now/soon to live ● No trouble with these
● 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 discharged home on a
cardiac monitor
● After birth, pt will be in the hospital for
few weeks
● Pediatrian/ peds nurse will likely refer pt
to a peds cardiologist
● T- words ● Ventricular septal defect (VSD)
○ Tetralogy of fallot ● Patent ductus arteriosus (PDA)
○ Truncus arteriosus ● Patent foramen ovale
○ Transposition of great vessels ● Atrial septal defect
○ Tricuspid atresia ● Pulmonic stenosis
○ Totally anomalous of pulmonary
vasculature (TAPV)
■ Except, left ventricular
hypoplastic syndrome
● R to L blood shunt
● Blue (cyonic)
● Murmur
● An echocardiogram needs to be done to find out the cause of the murmur

● 4 defects of tetralogy of fallot – “PROVe”; “VarieD PictureS OfA RancH”

○ Ventricular septal Defect
○ Pulmonary artery Stenosis
○ Overriding Aorta
○ Right ventricular Hypertrophy
○ (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 / universal
○ Contact
○ Droplet
○ Airborne

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Precautions Infectious DIseases PPE

Contact ● Anything enteric (GI/ fecal/ ● Private room
oral) – c.di , hepatitis A, E. ● Can be in the same room if cohort based
precaution
coli, cholera, dysentery on culture and NOT symptoms
● Staph ● Hand wash → gown → gloves
● RSV (droplets fall onto ● Disposable supply (gloves, paper plates,
object then pt touches object plastic utensils)
or put it in mouth; do not ● Dedicated equipment (stetho, BP cu )
cohort 2 RSV pts unless and toys stay in the room
culture and symptoms say
that have the same disease)
● Herpes
Droplet ● For bugs travelling on large ● Private room
particles through coughing, ● Can be in the same room if cohort based
precaution
sneezing to less than 3 feet on culture AND symptoms
● Meningitis ● Hand wash → mask → goggle or face
● H. influenza b (e.g., shield → gloves
epiglottitis – nothing in the ● Disposable supply
throat) ● Dedicated equipment
Airborne “MTV” ● Private room
● MMR ● Can be in the same room if cohort based
precaution
● TB on culture AND symptoms
● Varicella (chickenpox) ● Hand wash → goggle or face shield →
gloves
● Wear mask when leaving the room
● Keep door closed
● Disposable supply (not essential)
● Dedicated equipment (not essential)
● Negative pressure airflow

PPE
● Order for donning (putting on); reverse alphabetical order with mask for the second phase
○ Gown
○ Mask
○ Goggle
○ Gloves
● Order for do ng (taking o ); alphabetical order
○ Gloves
○ Goggle
○ Gown
○ Mask

Math problems
● Dosage calculation
● IV drip rates = volume x drop factor / time
○ Micro/mini = 60 drops/ml
○ Macro = 10 drops/ml
● Pediatric dose (2.2lbs = 1kg)

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LECTURE 4

Crutches, Canes, Walkers

● One of the major human functions is locomotion; pt teaching for use of crutches, canes, and
walkers is important
● For unstable gaits whose muscles are weak and who require a reduction in the load on
weight-bearing structures

Crutches
● How to measure the length of crutches?
○ It’s important for risk reduction to avoid nerve damage during ambulation
○ 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
(underarm),
■ the tip is located to a point lateral (6 inch) and slightly in front of foot (6 inch)
○ Rule out landmarks on foot or axilla!
● Hand grip measurement
○ The angle of elbow flexion is 30 degrees
○ The wrists should be at the level of the handgrip

How to teach crutch gaits?

● 2 point gait
○ Move a crutch and opposite foot together, then the other foot together
○ Together (right leg + left crutch) → together (left leg + right crutch)
○ For mild bilateral leg weaknesses
● 3 point gait
○ Move 2 crutches and bad leg together, followed by una ected leg
○ The gait goes 3-1, 3-1, 3-1
○ The a ected (bad) leg is not on the ground
○ The una ected (good) leg is on the ground
○ When one leg is a ected
● 4 point gait
○ Move all 4 separately
○ Move one 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, for severe bilateral leg problems
● Swing through
○ Similar to 3 point gait
○ The una ected food 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
○ For non-weight bearing (amputee)

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✴ NCLEX Tips ✴
● Use even-point gait for even, odd-point gait for odd
● Even-point gait when weakness is evenly/bilaterally distributed; 2 for mild 4 for
severe
● Odd-point gait when one leg is a ected; 3 for one leg
● Swing-through for non-weight bearing/ amputation

☁ Questions ☁
Q. Early stages of rheumatoid arthritis? 2-point
Q. Left ATK amputation post op day 2? Swing through
Q. Post op day 1, right knee, partial weight bearing allowed? 3-point
Q. Advanced stages of ALS? 4-point
Q. Left hip replacement, post op day 2, non-weight bearing? Swing through
Q. Bilateral total knee replacement, post op day 1, weight bearing allowed? 4-point
Q. Bilateral total knee replacement, post op 3 wks? 2-point

● Stairs with crutches

○ “UP with the GOOD, 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 first
○ No matter what, BOTH crutches always move with the BAD leg

Cane
● Hold cane on the una ected (good) side
● Advance cane with the opposite side for a wide base of support
● Handgrip should be at the level of wrist

Walker
● walker should be on the side of the pt
● “pt picks it up, sets it down, walks to it”
● “hold onto chair, stand up, then grab the walker”
● Don’t tie belongings to the front of the walker – tie them to either side so it won’t tip over

Psychiatry
● First thing to ask in psych question: “Is the patient psychotic or non-psychotic?”
● Non-psychotic: has insight and is reality-based
○ Technique to use for non-psychotic: good therapeutic communication (look at them
as med/surg pts)
○ E.g., “that must be very overwhelming for you”, “how are you feeling?”, “tell me about
your current feeling”
○ Look for “reflection, clarification, amplification, restatement”
● Psychotic: has NO insight and is NOT reality-based
○ They don’t think they are sick but everyone else has problem
○ Psychotic symptoms: delusions, hallucination, illusions

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■ Delusions: a false, fixed belief/idea/thought with NO sensory component (it’s

just a thought)
● Paranoid: “people are out to kill me”
● Grandiose: “I’m the president” “I’m the smartest person in the world”
● Somatic: “I have x-ray vision” “there are worms in my arm” – part of body
delusion
■ Hallucination: a sensory experience without a referent (nothing is actually
there)
● Auditory (#1), visual (#2), tactile (#3; feel), gustatory (taste), olfactory
(smell)
■ Illusion: misinterpretation of sensory reality with a referent in reality
● E.g., “listen, I hear demon voices” while nurses talk and laugh at the
nursing station: there is referent → illusion
● How do you deal with these psychotic patients?
○ FIRST, you should know what TYPE of psychosis they have
○ There are three types of psychosis: functional, dementia, delirium
■ Functional psychosis:
● They can function in everyday life
● 90% of psychosis falls under this category
● Schizophrenia, schizoa ective, major depression (not depression), mania
(bipolar pts have depression and mania and they are psychotic in acute
mania)
● Chemical imbalance in the brain
● They have potential to learn reality (no brain damage)
● Nurse should teach reality
● 1. Acknowledge feeling, 2. Present reality, 3. Set limits, 4. Enforce these
limits
■ Psychosis of dementia: actual brain destruction/damage
● Due to Alzheimer, stroke, organic brain syndrome
● Anything that says senile/dementia falls in this category
● They cannot learn reality so don’t present the reality
● 1. Acknowledge feeling, 2. Redirect them – give them something they can
do
● Do not confuse reality orientation (person, place, time) with presenting
reality
■ Psychosis of delirium: temporary, sudden, dramatic, episodic secondary to
something else (underlying cause should be treated)
● Loss of reality due to underlying cause (e.g., chemical imbalance)
● Causes: UTI, thyroid imbalance, adrenal crisis, electrolyte,
medications/drugs
● 1. Acknowledge feeling 2. Reassure about safety and temporariness of
their condition
● Psychotic symptoms
○ Flight of ideas: rapid flow of thought
○ Word salad: throw words together and toss it out (sicker than flight of ideas)
○ Neologisms: make up new words

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○ Narrow self-concept: refuses to change their clothes or refuses to leave their room
→ it’s functional, don’t make them psychotic to do something they don’t want to;
leave them alone!
○ Idea of reference: you think everyone is talking about you
● Dementia hallmark: memory loss, inability to learn
○ Acknowledge their feelings first
○ Then, Reassure, Redirect the Reality

Recap
● Approach to answering psych questions
1. Is pt non-psychotic? Or psychotic?
2. For non-psychotic, address pt as med/surg pts – using therapeutic communication
3. For psychotic, ask if they are functional, demented, or delirious
a. For functional = 1. Acknowledge feeling, 2. Present reality, 3. Set limits, 4. Enforce
these limits
b. For demented = 1. Acknowledge feeling, 2. Redirect them – give them something
they can do
c. For delirious = 1. Acknowledge feeling 2. Reassure about safety and
temporariness of their condition

LECTURE 5

Diabetes Mellitus (DM), Diabetes Insipidus (DI)

Diabetes Mellitus (DM)
● An error in glucose metabolism (glucose is the body’s primary fuel source)
● DM Type 1: lack of insulin
● DM Type 2: insulin resistance

Diabetes Insipidus (DI)

● DI is NOT a type of DM; insidious – diabetes without the glucose element
○ No glucose component here
○ It’s Polyuria, polydipsia leading to dehydration – due to low ADH
○ It’s just the fluid part
○ So, just like DM, DI have high urine output which leads to dehydration
● SIADH (Syndrome of inappropriate ADH – antidiuretic hormone): it’s the OPPOSITE of DI
○ So, SIADH presents with oliguria, no thirst, decreased urine output, leading to fluid
overload/water retention
○ And then, SIADH decrease serum specific gravity (due to water retention) and increase
urine specific gravity (due to decreased urine output)
● Nursing diagnosis of DM, DI, SIADH
○ Fluid overload/ urine retention, low specific gravity = SIADH
○ Fluid volume deficit/ dehydration = DM, DI
○ Fluid volume excess/ overload = SIADH

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Diabetes
● Type 1: insulin dependent, juvenile onset, ketosis prone
○ Treatment: “DIE” – diet, insulin, exercise
■ Insulin (#1) > exercise > diet (#3)
● Type 2: NON-insulin dependent, adult onset, NON-ketosis prone
○ Treatment: “DOA” – diet, oral hypoglycemic, activity
■ Diet (#1) > activity > oral med (#3)
■ Diet for DM2: primarily have to restrict calories (1200, 1400, 1600 kcal), and
they need to eat 6 small meals a day (smaller frequent meals) to keep the
blood sugar stable not to have spikes
■ Question: what is the best dietary action for DM2? Restrict calories or divide
meal into 6? Restrict the calories first!
● S&S of DM: polyuria, polydipsia (increased thirst), polyphagia (increased swallowing)

Insulin
What is Insulin
● They lower blood sugar level
● Used for T1DM (#1 treatment)

4 types of insulin
● Regular (R) – clear, IV drip, rapid/intermediate
o Onset: 1h
o Peak: 2h
o Duration: 4h
o Pattern: 1-2-4
● NPH (N) – cloudy, suspension (precipitate), no IV, intermediate
o Onset: 6
o Peak: 8-10
o Duration: 12
o Pattern: 6-8-10-12
● Lispro: Short acting – don’t give AC, give WITH the meal!
o Onset: 15 mins
o Peak: 30 mins
o Duration: 3 hrs
o Pattern: 15-30-3
● Glargin: long acting – little to no risk for hypoglycemia so this is the only insulin that can be
safely given HS
o No peak
o Duration: 12~24h

How would the board ask questions about peak of insulin?

● E.g., you give 30 units of insulin to a pt at 7am, when do you check for hypoglycemia?
● Answer: add the insulin peak time to the time of insulin administration
● Question: if the pt was given NPH at 7am, when do you check for hypoglycemia?
● Answer: NPH peak time is 8~10 hrs. therefore 7am + 8h~10h = 3pm~5pm

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Important facts about Insulin

● Always check the insulin expiration date!
● What action invalidates the manufacturer date?
o Opening the package
o Once the package is open, the new expiration date is 30 days after that
o Open package without an opening or expiration date should be thrown out
o Label the package with OPEN date or EXP date
o Once the package is open refrigeration is optional but, unopened insulin should be kept
in refrigerator (it is good practice teach pt to keep insulin refrigerated at home)
● Exercise potentiates insulin action
o Exercise is like another extra shot of insulin
o Therefore, if a pt is scheduled to exercise this afternoon, need to decrease the insulin
dose
o And the nurse must give the pt rapidly metabolized carbs – snacks or juice – after then
● Sick days – e.g., flu, fever
o When pt is sick, serum glucose goes up
o Therefore, their insulin needs to be given even if they didn’t eat / are not eating
o They tend to get dehydrated so, get them hydrated with sips of water
o Any sick DM patient has 2 problems – hyperglycemia + dehydration

Acute complications of DM
● Hypoglycemia/ hypoglycemic shock/ insulin shock/ insulin reaction
○ Causes: too much insulin (#1 cause; can lead to permanent brain damage), too
much exercise, not enough food
○ S/S: “Drunk Shock”
■ Drunk: staggering gait, slurred speech, cerebral impairment (labile), slow
reaction time, decreased social inhibition
■ Shock: vasomotor collapse – tachycardiac, tachypneic, hypotensive,
cold/clammy/ mottled skin
○ Tx:
■ Give sugar/ rapidly metabolized carbs: any juice, candy, regular soda,
lactose/milk, honey, icing, jelly, jam
■ The best answer: sugar + starch/ protein – e.g., apple juice + turkey
■ Bad answer: candy + soda = two sugars – two or more sugar is not the best
answer
■ For unconscious pts: do NOT give PO! Give glucagon IM if pt is at home, give
Dextrose IV in ER (D10 or D50)
● DKA (diabetic ketoacidosis) = hyperglycemia in T1DM with ketones in
blood
○ Causes: acute viral upper resp infection within last 2 wks (#1 cause), too much
food, not enough insulin, not enough exercise
○ S/S: “DKA”
■ Dehydration (dry, poor skin elasticity and skin turgor, warm – water is coolant
so having less water mean you overheat)

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■ Ketones in serum, Kussmauls, High K+ (Note: ketone in urine doesn’t

necessarily mean DKA)
■ Acidosis, acetone breath, anorexia due to nausea
○ Tx:
■ IV insulin (Regular)
■ IV fluid (faster rate – e.g., 200ml/hr)
● HHNK / HHS / HHNS: hyperglycemia in T2DM
○ They don’t burn ketones – no acid
○ Whenever you see HHNK, think of dehydration!
○ S/S: Severe dehydration!!! (dry, flushed, decreased skin turgor, increased HR)
■ #1 nursing Dx: FVD (=dehydration)
■ #1 nursing tx/intervention: rehydration
■ Outcomes in successful tx: increased U/O, moist mucous membrane
■ Long term complications: poor perfusion, peripheral neuropathy

DKA vs. HHNK

● Which one is more insulin dependent? DKA pts (T1DM) are more dependent on insulin, HHNK
pts needs to be rehydrated
● Which one has a higher mortality rate? More pts die from HHNK
● Which one is the more priority case? DKA is more priority as it responds very quickly to insulin
whereas HHNK pts do not readily respond to treatment

Long term complications of DM

● Related to: poor tissue perfusion OR peripheral neuropathy
● Examples of L-T complications: Renal failure, Gangrene, Heart Failure, Urinary incontinence,
pt can’t feel a burn on the foot
○ Renal failure leads to poor perfusion
○ Urinary incontinence leads to peripheral neuropathy
● Lab test for long term blood sugar level?
○ Hb A1C (= glycosylated Hb/ glycosylated Hb): average blood sugar over last 90 days
○ Hb < 6 is normal
○ Hb > 8 is out of control
○ Hb 7 = borderline – needs further evaluation/ assessment

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LECTURE 6

Drug Toxicity (5 drugs)

Indication Therapeutic Toxic level others
level
Lithium Bipolar disorder 0.6 – 1.2 > 2.0 Gray area
(antimania) - for manic 1.3 – 2.0
episodes not for
depression
Lanoxin/ Digoxin A-fib, CHF 1–2 > 2.0
Aminophylline Muscle spasm 10 – 20 > 20 Non-therapeutic
(compound of relaxer for airway level: < 10 (in this
bronchodilator case, increase
theophylline) dose and assess
for compliance)
Dilantin Seizure 10 – 20 > 20
(Phenytoin) medication
Bilirubin Breakdown 0.2 – 1.2 for adults
Elevated level for Hospitalize
produce of RBCs Higher for newborn: 10 – 20 newborn if bili is >
NEWBORN Toxicity for 14
newborn > 20
● Memory tip: 1-2 or 10-20 → Lows #s Lithium and Lanoxin (1s and 2s)
3 problems from bilirubin level
● Jaundice: yellow skin from excess bili in blood, appears as yellow skin and sclera
○ Pathological: jaundice within first 24h of birth – concerning
○ Physiological: jaundice 2 to 3 days postpartum – normal
● Kernicterus: excess bili in the brain (bili>20), in the brain it may cause aseptic/sterile
meningitis or encephalopathy
● Opisthotonos: hyperextended position that the newborn assumes d/t irritation of the
meninges from kernicterus (medical emergency!)
○ Question: What position do you place an opisthotonous newborn? Put them on the
side!

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Hiatal hernia Vs. Dumping Syndrome (they are opposite situations)

Hiatal Hernia Dumping syndrome (“Drunk Shock
Abdo distress”)
What is it Regurgitation of gastric acid Gastric contents are dumped too
upward/backward into esophagus quickly into duodenum
- wrong direction - right direction
- correct rate - wrong rate (too quick)

S/S Similar to GERD (heartburn and “Drunk Shock” + abdo distress

indigestion) when lying down after a - Drunk: staggering gait, impaired
meal judgement, labile – all blood gone to
- heartburn, indigestion, lying down gut
after a meal - Shock: cold/clammy, tachycardic,
pale
- abdo: n/v/d, cramp, guarding,
borborygmi, bloating, distention
Treatment 3 things (“everything high”) 3 things (“everything low”)
- HOB - Elevate HOB 1h post meal - lower HOB during meals and turn pt
- H20 - increase fluid amount with meals on the side
- Carbs/ protein - increase carb content, decrease - decrease fluid amount 1 to 2 h
protein before or after meals
(They make stomach to empty - decrease the amount of carb,
quickly so content doesn’t go back increase protein
up) (They prevent stomach from
emptying too quickly)

● Note: protein does the opposite of carbohydrate; protein bulks gastric content and takes
longer to digest and moves slower through the gut
○ Therefore, give low protein for hiatal hernia and high protein for dumping syndrome

Electrolytes
Memorize these
1. Kalemias (K+) do the same as the prefix except for HR and U/O
2. Calcemias (Ca2+) do the opposite as the prefix
3. Magnesemias (Mg2+) do the opposite as the prefix
4. Hyponatremia = FVO, Hypernatremia = Dehydration (FVD).

1. K – Kalemia
● Go in the same direction as the prefix except for HR and UO, which go in opposite direction
● Hypo – symptoms go low with hypo while HR and UO go up
○ Lethargy, bradypnea, paralytic ileus, constipation, muscle flaccidity, hyporeflexia (0,
1+), tachycardia, polyuria
● Hyper – symptoms go high with hyper while HR and UO go down

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○ Seizure, agitation, irritability, tented T wave, ST elevation, tachypnea, diarrhea,

borborygmi, spasticity, increased tone, hyperreflexia (3+,4+), bradycardia, oliguria

2. Ca – Calcemia
● Go in the opposite direction as the prefix
● Hypo – symptoms go high
○ Agitation, irritability, 3+4+ reflexes, spasm, seizure, tachycardia, Chvostek sign (tap of
cheek), Trousseau (inflate BP cu ), etc
● Hyper – symptoms go low
○ Bradycardia, bradypnea, flaccid, hypoactive reflexes, lethargy, constipation

3. Mg – magnesium
● Go in the opposite direction as the prefix (in a tie between Ca and Mg, don’t pick Mg!)
● Hypo – symptoms go high
○ Agitation, irritability, 3+4+ reflexes, spasm, seizure, tachycardia, Chvostek sign (tap of
cheek), Trousseau (inflate BP cu ), etc
● Hyper – symptoms go low
○ Bradycardia, bradypnea, flaccid, hypoactive reflexes, lethargy, constipation

4. Na – sodium (dehydration vs. fluid overload)

● Dehydration – hypernatremia, hot flushed skin > then, give lots of fluids
● Fluid overload – hyponatremia > then, give Lasix and restrict fluid

Earliest sign of any electrolyte imbalance = numbness and tingling (aka Paresthesia)
● Circumoral paresthesia: numb/tingling lips
● All electrolyte imbalances cause muscle weakness (aka Paresis)

Treatment of Potassium Imbalances

● Tx for low K+: give K+
○ Never push IV K+
○ Never give more than 40 K+/L of IVF
● Tx for high K+ (more dangerous since it can stop heart)
○ Fastest way to lower K+: give D5W + regular insulin
■ K+ enters early – temporary but works fast
■ K+ in blood will kill you, not K+ in cells
■ D5W + reg insulin will push K+ into cells from blood
○ Kayexalate
■ K+ exits late – takes hours but permanent
■ It’s full of Na+, given via enema or PO
■ Trades Na+ for K+ so you shit it out → results in hyperNa+ (dehydration) so,
give fluids to correct it
○ Best way to lower K+ is using BOTH!

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LECTURE 7

Endocrine
● Focus on the Thyroid & Adrenal Glands
● Thyroid = Metabolism (thyroid regulates the metabolism rate)

Thyroid
Hyperthyroidism
● = “Hypermetabolism”
● S/S (when your metabolism goes up): weight loss, high HR & BP, irritable, heat intolerance,
cold tolerance, exophthalmos (bulging eyes)
● Called GRAVES disease (running yourself into the grave)
● Treatments:
○ Radioactive Iodine
■ Patient needs to be by themself for 24 hours (restriction of visitors)
■ Be very careful with their urine (flush 3 times)
■ If the urine is spilled, you must call the hazmat team! Biggest RISK to the Nurse is
the patient’s urine (how the radioactivity is excreted)
○ PTU (propylthiouracil) *Puts Thyroid Under*: cancer drug
■ it is an immunosuppressor → monitor WBCs
○ Thyroidectomy (most common tx) - TOTAL (complete) or SUBTOTAL (partial)
thyroidectomy*
■ TOTAL: need lifelong hormone replacements; at risk now for HYPOcalcemia
(since parathyroid which controls Ca level is hard to save during total → Positive
Trousseau’s & Chvostek's signs)
■ SUBTOTAL: do NOT need lifelong hormone replacements
● at risk now for THYROID STORM/CRISIS THYROID Storm
● Thyroid Storm: medical EMERGENCY
○ 1. super HIGH temps (105 & >)
○ 2. extremely HIGH BP’s (e.g., 210/180 (stroke category!)
○ 3. severe TACHYCARDIA (ex: 180-200)
○ 4. PSYCHOTIC DELIRIUM (medical emergency; can cause brain damage while frying the
brain to death)
○ Immediate Tx: Get temperature DOWN & get the oxygen UP!
■ FIRST way to get temp down: ice packs
■ BEST way to get temp down: cooling blanket
■ OXYGEN (per mask @ 10L)
■ Do not use Tylenol - it works in the hypothalamus and isn’t going to work at this
time
■ FYI: If it’s a sequence question: oxygen, ice packs, cooling blanket.
■ NEVER, EVER leave patient!
● Post OP RISKS
○ 1st 12 hours: priority = airway & hemorrhage
○ 12-48 hours: TOTAL: Tetany (muscular spasms in larynx can cut o airway) due to low
calcium; SUBTOTAL: Thyroid storm

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○ >48 hours (42-72h): INFECTION

■ NEVER choose infection as a PRIORITY in the first 72 hours for anything

HYPOthyroidism
▪ HYPOthyroidism = HYPOmetabolism
▪ S/S: obese, cold intolerance, heat tolerance, low pulse & BP = MYXedema
▪ Treatment: give them thyroid hormones: synthroid (levothyroxine)
▪ *CAUTION* do NOT sedate these patients; can put them in a coma
▪ What pre-op order would you question? AMBIEN @ HS.If the patient is supposed to be NPO;
make sure you question that they still get their morning pill!! (NEVER hold your thyroid pills
unless you have EXPRESS orders to do so).

ADRENOCORTEX Disease (start with A & C)

● ex: Cushings, Conns, Addisons
ADDISON'S Disease: UNDER secretion of the adrenal cortex
● S/S: HYPERpigmented (tanned) & do NOT adapt to stress (your stress response is to raise
your glucose & BP!) -these people can’t do this; glucose & BP goes down = go into shock!
Anything from a tooth filling at the dentist or a minor fender bender can cause these people
to stress out & die
● TICKING TIME BOMB!*ADDISONS is one of the RAREST endocrine disorders*
● ex: for every 600 CUSHING'S patients, there’s 1 ADDISON'S patients.
● *JFK had this dx; so when he was shot (even if it was in his shoulder & not his skull), there was
never any chance for survival*
● Treatment: glucocorticoids (steroids; all end in “sone” ex: prednisone, dexamethasone &
hydrocortisone.
● Remember: ADDISONS “ADD a SONE”!!

CUSHING'S Disease: OVER secretion of the adrenal cortex (cushy = more!)

● S/S: pu y moon face, hirsutism (facial hair), truncal
obesity (big body), gynecomastia (female breasts on
men), bu alo hump, skinny arm & legs (muscles waste
away), retain sodium & water; losing potassium, striae
(stretch marks), bruising, (“I’m mad; I have an infection”;
grouchy/irritable & immunosuppressed) & HIGH glucose
*most important to remember!!* (hyperglycemic)
● “Cushman” (know this picture!)
● Treatment: ADRENALectomy (bilateral) – this can cause
Addison’s though; so they need steroids; making you look
like CUSHman again

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KIDS TOYS
● 3 questions to ALWAYS ask
○ Is it SAFE?
○ Is it AGE APPROPRIATE?
○ Is it FEASIBLE? (possible to do easily or conveniently)
● SAFETY considerations
○ NO SMALL TOYS for children UNDER 4 (could put in mouth/aspirate)
○ NO METAL (die-cast) TOYS, if OXYGEN is in use.. (sparks!)
○ BEWARE of FOMITES (= non-living object that harbors microorganisms)
○ What toys are the worst for FOMITES? Stu ed animals
○ What toy is the best for FOMITES? Hard plastic toys/you can disinfect it!
○ *BEST toy for an IMMUNOSUPPRESSED child? HARD PLASTIC
● FEASIBILITY consideration
○ Could they do it? ex: Is swimming a good activity for a 13 year old?
○ Safe; yes, Age appropriate; yes, Feasible for a kid in a body cast? NO!
● AGE-APPROPRIATE considerations
○ Infant 0m -6m: BEST toy: musical mobile *stimulates motor & sensory*.2nd BEST
toy: something SOFT & LARGE
○ Infant 6m -9m: *working on object permanence*: they know it’s still there even
though they can’t see it* ex: you put a toy under a blanket - if they don’t have it;
they’ll cry, if they have it: they know to lift the blanket & get it. At this age, your
“play” should be teaching them that; that is their big task at this time. BEST toy:
cover/uncover toy; play PEEK-a-BOO, the parent putting a blanket over their
head and then taking it o , Jack-in-the-Box, etc.2nd BEST toy: something
large/hard. WORST toy: musical mobile; they can sit up/reach up and then can
strangulate themselves
○ Infant 9m -12m: *working on vocalization*: BEST toy: speaking toys; ex: “Talking”
Woody (Toy Story!), Tickle Me Elmo, Teddy Ruxpin, See & Say: “the COW says
MOO”, etc. They also need PURPOSEFUL ACTIVITY. NEVER PICK THESE ANSWERS
if the kid is UNDER 9m: build, sort, stack, make, construct - why? PURPOSE words!
○ Toddlers 1-3: Best toy: PUSH/PULL.. ex: lawn mower, baby stroller *work on
GROSS MOTOR; running, jumping* NO finger dexterity yet; can’t color, use
scissors, etc. “Finger painting”, yes, because they can use their HAND! Finger
painting = HAND painting. They do PARALLEL Play (play along-side, but not with)
○ Preschoolers: work on their FINE MOTOR (finger dexterity), work on BALANCE
(tricycles, dance class, ice-skates) Characterized by CO-OPERATIVE play (play
together in groups). They like to PRETEND; highly imaginative! School Age
Characterized by the 3 C’s-Creative (blank paper & colored pencils) -Collective
(collect anything & everything) -Competitive (they don’t like being the loser)
○ Adolescents: Peer Group Association (hang out with their friends); Q. Do you let
5-8 adolescents hang out in a room together? YES! UNLESS these 3 things: if
anyone is fresh post-op (less than 12 hours out of surgery), if anyone is
immunosuppressed, & if anyone has a contagious disease.

LAMINECTOMY (neuro)
Laminectomy: (is surgery that creates space by removing the lamina - the back part of the vertebra
that covers your spinal canal. Also known as decompression surgery, laminectomy enlarges your
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spinal canal to relieve pressure on the spinal cord or nerves). lamina = vertebral spinous processes
(posterior) ectomy = removal
● WHY do you do this?? RELIEVE NERVE ROOT COMPRESSIONS/S of nerve root compression
● S/S: 3 P’s – pain, paresthesia (numbness & tingling), paresis (muscle weakness)
● MOST IMPORTANT thing to pay attention to any NEURO question = LOCATION! 3 locations for
laminectomy:
○ Cervical (neck),
○ Thoracic (upper back)
○ Lumbar (lower back)
● Pre-op assessment:
○ Cervical: Airway & function of arms/hands
○ Thoracic: Cough/Bowel mechanisms
○ Lumbar: Bladder- when was the last time they voided? & leg function
● Post op spinal #1 answer: log roll**
○ DON’T DANGLE THE PTS LEGS!
○ DON’T SIT FOR LONGER THAN 30 MINS!
○ THEY MAY WALK, STAND, LAY DOWN W/O RESTRICTION
● Complications:
○ Cervical: Pneumonia
○ Thoracic: Pneumonia & Paralytic Ileus
○ Lumbar: Urinary retention followed by leg problems
● Discharge teaching: 4 temporary restrictions (6 weeks)
○ Don’t sit for longer than 30 mins
○ Lie flat & log roll
○ No driving
○ Do not lift more than 5 pounds (gallon of milk)
● Permanent restrictions:
○ Never lift objects by bending with the waist
○ Cervical lams not allowed to lift ANYTHING over their head
○ No jerking, horseback riding, 6 flags
● Terms:
○ Anterior Thoracic: From the front thru the chest to the spine
○ Laminectomy w/ fusion: Bone graft from the iliac crest 2 incisions, one on the hip &
one on the spine
■ Hip has most pain/bleeding/draining
■ Both have equal risk for infection
■ Spine has highest risk of rejection

- Remember: MOST IMPORTANT thing to pay attention to in *any* NEURO question =

LOCATION!

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LECTURE 8

Lab Values
Rank them
.A - (Abnormal) - Do nothing
B - (Be concerned) - Assess/monitor
C - (Critical) - Do something, you can leave the bedside
D - (Deadly/Dangerous) - Do something now, NEVER LEAVE BEDSIDE OF D**

Normal Level Abnormal Level

Serum Creatinine 0.6-1.2 unless question says they have a dye procedure
in the morning
INR 2-3 (on warfarin) C) anything 4+

K+ 3.5-5.3 C) low or high

D) K equal/over 6
pH 7.35-7.45 D) anything in the 6’s
BUN 8-25 A) Assess for dehydration
Hgb 12-18 B) 8-11: Assess for anemia/bleeding/malnutrition
C) < 8: Assess for bleeding, prepare to give blood,
call Dr.
Bicarb 22-26 A)
CO2 35-45 C) 46-59: assess respirations, prepare to do
pursed lip breathing
D) equal/over 60: assess respirations, prepare for
intubation/ventilation, call RT, then call Dr.
Hct 36-54 (= 3X Hgb) B) 54+: assess for dehydration
PO2 78-100 C) Low 70’s: assess resp, prepare 02
D) 60s and lower = hypoxia: give 02, assess resp,
prepare for intubation/ventilation, call RT, then
call Dr.
O2 93-100 C) <93: assess resp, raise HOB, give O2 (“best”
question: just give O2)
BNP <100 B) 100+: look for signs of CHF

Na 135-145 B) with no change in LOC

c) with change in LOC
Plt 150K-450K C) < 90K
D) <40K
RBC 4-6m B) lower/higher
WBC 5K-11K C) < normal value
ANC 500+ - low CD4 = AIDs
CD4 200+ - place on Neutropenic Precautions
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Neutropenic Precautions
● Strict Hand washing
● Shower BID with antimicrobial soap
● Avoid Crowds
● Private Room
● Limit numbers of sta entering room
● Limit Visitors for Healthy Adults
● No fresh flowers or potted plants
● Low Bacteria Diet: No Raw Fruits, Veggies, Salads
● No Undercooked meat.
● Do not drink water than has been standing longer than 15 minutes
● Vital signs (Especially Temperature) every 4 hours
● Check WBC (ANC) Daily
● Avoid the use of an indwelling catheter
● Do not re-use cups.. must wash between uses
● Use disposable plates, cups, straws, plastic knife, fork, spoon
● Dedicated Items in Room:
● Stethoscope
● BP Cu
● Thermometer
● Gloves
● ASSESS FOR INFECTION!

What do you do when something is Critical

1. Always hold/stop it first
2. Assess
3. Prepare to give
4. Call the doctor

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LECTURE 9

Psych Drugs
┖ * All psych drugs cause hypotension & weight gain *

Phenothiazines: 1st Gen / Typical Antipsychotics

● All end in “zines”
● They don’t cure psych diseases, only reduce symptoms
● Zines for the zaney*
● ZzZ.. zines (sedatives)
● Small doses are anti-emetics
● Major tranquilizers
● *DO NOT confuse “zeps” for “zines”
● Side E ects: Non-toxic
○ Anticholinergic (dry mouth)
○ Blurred vision
○ Constipation
○ Drowsiness
○ EPS- extrapyramidal syndrome (Pill rolling, cogwheel rigidity, shu ing gait)
○ Fotosensitivity
○ aGranulocytosis (Low WBC immunosuppressed)
● If Pt Displays Side E ect:
○ Teach pt to keep taking the drug
○ Inform the Dr
○ Keep taking the pill
○ Treat the side e ects
● If Pt Displays Toxic E ects:
○ Hold the drug & call the Dr immediately
○ Nursing dx risk for injury/safety issues

Tricyclic Antidepressants: Grandfathered into a new class called NSSRI’s

● **Take for 2-4 weeks before you see e ects**
● E.g., Elavil, Tofranil*, Avatil, Desyrel
● Elavil elevates your mood
● Anticholinergic (dry mouth)
● Blurred vision
● Constipation
● Drowsiness
● Euphoria (way too happy)

Benzodiazepines: Minor tranquilizers

● They always have “zep” in the name
● ZzZ.. Zep (sedative)
■ A- Pre-op to induce anesthesia
■ B- Muscle Relaxer

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■ C- Alcohol Withdrawal
■ D- Seizures
■ E- Help when pt is fighting the ventilator to calm down
● They work quickly but DON’T take them for more than 2-4 weeks
● AD’s take a long time to work but you can take it for the rest of your life
● Mild tranquilizers work right away but can’t be on long
● Heparin is to Coumadin as to tranquilizer is to an antidepressant
● *DO NOT confuse “zeps” for “zines”
● Side e ects:
○ Anticholinergic (dry mouth)
○ Blurred vision
○ Constipation
○ Drowsiness
● #1 Dx is injury

MAOis: Monoamine Oxidase Inhibitors

● Beginning of the names all rhyme
● Eg., Partite, Nardil, Marplan, (Par, Nar, Mar) or PaNaMa
● Pt Teaching:
○ To prevent hypertensive crisis, avoid all foods containing tyramine
○ Salad BAR
○ Bananas
○ Avocados
○ Raisins (dried fruit)
○ Organ/preserved/hot dogs/lunch meats (smoked, dried, cured, pickled, etc.)
○ No dairy EXCEPT for mozzarella and cottage cheese
○ No yogurt
○ No alcohol
○ No chocolate
○ Don’t take OTC meds while on MAOi’s

Lithium: Bipolar disorder

● Decreases mania, not depression
● Only psych drug that doesn’t mess with neurotransmitters
● Side E ects: 3 P’s- Peeing, Pooping, Paresthesia
○ Give & don’t call the Dr
● Toxic e ects: Tremors, metallic taste, severe diarrhea
○ Hold & call Dr.
● #1 Intervention while on the med:
○ Increase fluids
○ If they’re sweating, don't give them water. Give Gatorade/PowerAde (electrolytes)
○ Monitor for dehydration & sodium levels
○ (Low sodium = makes lithium toxic / High sodium = lithium won’t work)

Prozac: SSRI. Similar to Elavil

● Side E ects:
○ Anticholinergic (dry mouth)
○ Blurred vision
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○ Constipation
○ Drowsiness
○ Euphoria (way too happy)
○ Insomnia - Give BEFORE noon, NOT at bedtime
○ Increased suicide risk when changing doses with young adults

Haldol: Schizophrenic, similar to Thorazine, Typical 1st Gen Antipsychotic

● Side E ects:
○ Anticholinergic (dry mouth)
○ Blurred vision
○ Constipation
○ Drowsiness
○ EPS- extrapyramidal syndrome (parkinson’s symptoms) no big deal
○ Fotosensitivity
○ aGranulocytosis (immunosuppressed) (destroys marrow)

*****NMS: Neuroleptic Malignant Syndrome******

▪ Haldol overdose
▪ Young white men & elderly dudes can get it from overdose
▪ Potentially fatal hyperpyrexia (105-108)
▪ Includes anxiety and tremors
▪ Give elderly half of adult dose
▪ Take the temp to tell the di erence from EPS

Clozaril/Clozapine: 2nd Gen Atypical Antipsychotic

▪ Used to treat severe schizophrenia, made to replace the *zines and haldol
▪ Does NOT have the side e ects (A-F)
▪ Has SEVERE agranulocytosis (immunosuppressed)
▪ Monitor WBCs, they can fall very low

Geodon (Ziprasidone):
▪ Black box warning- Prolongs QT interval and can cause sudden cardiac arrest, DON’T give to
people with heart conditions.

Zoloft (Sertraline):
▪ SSRI, can cause insomnia but you can give it at bedtime
- *Zoloft interferes with this system increasing toxicity with other drugs*
▪ Therefore, lower the dose of other drugs
▪ Warfarin/Coumadin must be reduced because you can bleed out
▪ St. John Wort + Zoloft = Serotonin syndrome* DON’T TAKE St. John Wort
▪ Sweating
▪ Apprehension/impending sense of doom
▪ Dizziness
▪ HEADaches

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LECTURE 10

Pregnancy
● Estimated date of delivery – use Naegele Rule: First day LMP + 7 days – 3 months
○ E.g., If LMP between June 10 to June 15, June 10 + 7 days – 3 months => March 17th
● Weight gain during pregnancy
○ 1st tr (12wks; 3 months) – 1 lb per month = total of 3 lbs
○ 2nd and 3rd tri – 1lb per week
○ The ideal wt gain during pregnancy: 28+/- 3 = 25~31 lbs
● How to calculate ideal wt gain: # of week – 9 (+/-2) ---- WNR
○ If wt gain is +/- 3lbs … assess the pt
○ If wt gain is +/- 4lbs … there is trouble → perform BPP on the fetus

● Fundal height
○ Cannot be palpated until wk 12; when F(fundus) is at midway between umb and pubic
symphysis
○ Between wk 20~22: F can be palpated at the umbilicus
○ Significance of being able to palpate fundal height: examiner can determine in what
trimester the pregnancy is (in case of pt is unconscious), diagnostic significance as well
when bigger than normal fundus may indicate molar pregnancy (cancer)
● 4 Positive signs of pregnancy
1. Fetal skeleton on x-ray
2. Presence of fetus on ultrasound
3. Auscultation of FHR (doppler) – 8~12 wks
4. Palpable fetal movement (outline) – by the examiner (not by the mother)

Ranges of values
● In OB questions, there are 3 types of Q’s re: range of values.
● For example, the FHR can be heard first between 8 to 12 wks. Quickening (baby Qicks) may be
first felt between 16 to 20 wks.
1. When would you FIRST?
This is the earliest date

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FHR: 8 wk
Quickening: 16 wk
2. When would you MOST LIKELY?
This is the date midway in the range
FHR: 10wk
Quickening: 18 wk
3. When should you ____ BY?
This is the latest date
FHR: 12 wk
Quickening: 20 wk

Maybe signs of pregnancy

● Positive urine/ blood hCG tests
○ But, positive pregnancy test may result from other conditions like cancer
● Chadwick sign: Cervical Color Change to Cyanosis (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)
● Alphabetical order – C, G, H; Move up from the vulva, vagina, cervix, to uterus

Patient teaching for prenatal visit

● Once a month until wk 28
● Once/ 2 wks – wk 28 and 36
● Once/ wk – after wk 36 to delivery or wk 42 (whichever comes first) – at wk 42 delivery can be
induced or by c-section
● E.g., if a woman comes in for her 12 week prenatal check-up when is her next prenatal visit? 16 wk

Lab values
● Hemoglobin level will fall during pregnancy
○ Normal Hb in female = 12~16
○ Pregnant woman can tolerate lower levels of Hb
○ 1st tri: can fall to 11 and be normal
○ 2nd tri: can fall to 10.5 and be normal
○ 3rd tri: can fall to 10 and be normal
○ If Hb<9, anemia evaluation needed

Common Symptoms for Pregnant Women

Morning sickness
● Seen during 1st tri
● Tx: dry carbs before pt gets out of bed (not before breakfast)
Urinary incontinence
● Seen during 1st tri and 3rd
● Tx: void Q2hrs from the day she gets pregnancy until 6 wks postpartum
Di culty breathing
● During 2nd and 3rd tri
● Tx: tripod position – physical stance that is often assumed by people with resp distress (like
COPD); lean forward, hands on knees/desk

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Back pain
● Seen during 2nd and 3rd tri
● Tx: pelvic tilt exercises (put foot on stool then back again)

Labor and birth

● Truest most valid sign that she is in labor: onset of regular/progressive contractions

To know
● Dilation: OPENING cervix from 0 (closed) to 10 cm (fully dilated)
● E acement: THINNING of the cervix; goes from thick to 100% e aced (thin like paper)
● Station: relationship between fetal presenting part and the mother’s ischial spines (***know
this***) – narrowest part of the pelvis
o Positive numbers mean the baby has made it through this tight squeeze = good to go
o Positive numbers = positive news
o If baby is at -3,-2,-1, it can’t get through vaginally → requires C-section
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● Engagement: station ZERO – this means the presenting part is AT THE ISCHIAL spines

Lie
● Lie is the relationship between the spine of the mom and spine of the baby
● Vertical lie (parallel spines) – good > compatible with vaginal birth
● Transverse lie (perpendicular spines) – bad > trouble → c-section

Presentation (just guess this question) – most common ones are ROA or LOA
● ROA (best fetal position)
● LOA
● Pick ROA before LOA
● *Before giving digitalis, always take an apical HR*

4 stages of labor
● Stage 1: onset of labor (priority/purpose: cervical dilation and e acement)
○ Phase 1: LATent
○ Phase 2: Active (priority: pain management)
○ Phase 3: Transition (priority: checking dilation, helping pregnant mom with breathing, pain
management)
● Stage 2: delivery of baby (priority: clearing baby’s airway)
● Stage 3: delivery of placenta (priority: assess placenta for smoothness and intactness and make
sure 3 vessels umbilical cord present)
○ PP begins 2hrs after delivery of placenta!
● Stage 4: recovery (priority: stop bleeding) – 2 hours until bleeding stops

Stages and phases of labor

Stage 1 – onset of labor
● Phase 1: latent

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○ dilation from 0 to 4 cm
○ contraction 5 to 30 mins apart
○ lasts 15 to 30 secs
○ mild intensity
● Phase 2: active – memorize this part
○ dilation from 5 to 7 cm
○ contraction 3 to 5 mins apart
○ lasts 30 to 60 secs
○ moderate intensity
● Phase 3: transition
○ dilation from 8 to 10 cm
○ contraction 2 to 3 mins apart
○ lasts 60 to 90 secs
○ strong intensity
Stage 2 – delivery of baby
● Deliver head
● Suction the mouth then nose
● Check for nuchal (around the neck) cord
● Deliver shoulders then body
● Baby must have ID band on before leaving the delivery area
Stage 3 – delivery
● Make sure it’s all there
● Check for a 3 vessel cord- 2 arteries 1 vein – “AVA”
Stage 4 – Recovery, contract the uterus to stop bleeding
● Postpartum technically begins 2 hours after the placenta comes out
● 4 things you do 4 times (q 15 min) an hour in the 4th stage:
● Vital Signs: Looking for S/S of shock (pressures go down, rates go up, cold and clammy)
● Fundus check: If boggy=massage, if displaced= void / catheterize
● Pads: Check pad saturation. If bleeding excessively she will saturate a whole pad (100%) in 15
mins or less, if 98% saturated it’s okay. She should not soak a pad in one hour or less due to
the risk of hemorrhage.
● Roll her over: check for bleeding underneath her

**PAY ATTENTION TO THE Q: PHASES ARE NOT STAGES! **

*** contraction should be NO LONGER than 90 secs and NO CLOSER than 2 mins***
● E.g., the sign of uterine tetany, parameters re: uterine contraction that make you stop Pitocin,
uterine hyperstimulation? They are all NO LONGER THAN 90 Secs, NO CLOSER THAN 2 MINS

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How to time contractions

● Frequency of contraction: BEGINNING of contraction to the BEGINNING of the next

● Duration of contraction: from Beginning to end of one contraction
● Intensity of labor: It’s 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 of them, know them all, but only 3 protocols focus on these
three protocols)
● Painful back pain – “OP” = Oh Pain. What do we do?
○ POSITION THEN PUSH
○ Position: KNEE – CHEST position Then,
○ PUSH with fist into sacrum to use counter pressure
○ “OP” … anything Occiput Posterior

● Prolapsed Cord – OB emergency

○ When the cord comes first and head presses cord and baby dies
○ High priority
○ PUSH then POSITION
○ Push the head o the cord of fetus then,
○ Position knee-chest or Trendelenburg
● Interventions for all other complications
○ Tetany, maternal hypertension, vena cava syndrome, toxemia, uterine rupture
○ They are all treated the same with “LION”
■ Left side – place mom on left side
■ IV – give IV
■ Oxygen
■ Notify HCP
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■ If pit is running during OB crisis, the first thing to do STOPPING PIT → THEN LION
● When to administer systemic pain meds
○ Do not administer a systemic pain med to a woman in labor if the baby is likely to be born
when the med is at its peak
○ E.g., you have a primigravida at 5cm dilated who wants her IV push pain med (peak at
15~30mins). What is nursing intervention? You CAN give pain med
○ E.g., you have a multigravida at 8cm and wants her IM pain med (peak 30 to 60 mins). What
is nursing intervention? DO NOT administer the pain med

LECTURE 11

Fetal monitoring Patterns

● There are 7 fetal monitoring patterns to learn. The ones that start with “L” are BAD heart
tracing. Use “LION” as the nursing intervention here as well!
● Normal FHR = 120~160 bpm

1. Low FHR <110

● BAD
● >> You hold Pit if running then, do “LION”
2. High FHR >160
● Document acceleration of FHR
● Take mom’s temp (mom is maybe febrile)
● Not a crisis – baby is WNL
3. Low baseline Variability
● BAD
● When FHR stays the same - it doesn’t change
● >>You hold Pit if running then, do “LION”
4. High baseline variability
● FHR is always changing – this is GOOD
● Document the finding

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● Notice that in utero, low variability of VS is a bad sign and high variability VS is a good sign
not like after you are born
5. Early deceleration
● This is normal – maybe due to head compression
● Document finding
6. Variable (very) deceleration
● This is VERY BAD
● Indicates PROLAPSED CORD
● >> So, you do PUSH and POSITION
7. Late decelerations
● This is BAD – due to placental insu ciency
● >> You hold Pit if running then, do “LION”
***there is one answer that always win: CHECK THE FHR***

2nd stage of L&D: delivery of the fetus – know the order***

● Deliver HEAD
● SUCTION THE MOUTH → NOSE
● CHECK for NUCHAL (around neck) cord
● Deliver the SHOULDERS → BODY
● Make sure baby has ID BAND on before it leaves delivery area

3rd stage of L&D: placental delivery

● Make sure placenta is complete and intact
● Check for 3 vessels cord – “AVA”; 2 arteries, 1 vein

4th stage of L&D: Recovery

● There are 4 things you do 4 times in an hour (Q15 mins) in 4th stage
1. VS: assess for shock (BP goes down, HR goes up, pale, clammy, cold)
2. Fundus: if boggy, massage it; if displaced void/catheterize it
3. Perineal pads: excessive bleeding if it saturates in 15 mins or less
4. Roll pt over and check for bleeding under her

PostPartum Assessment
● Assess Q4~8H
● Assess for “BUBBLE HEAD” (three big important things: FUNDUS,
LOCHIA, THROMBOPHLEBITIS)
○ Breast
○ Uterine fundus should be FIRM***
■ Massage if F is boggy and midline
■ Cath pt if fundus is boggy and NOT midline
■ What should the PP uterine tone, height, and location
normally be like?
● Tone of F = firm, NOT boggy

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● Height of F = at umbilicus/ navel (fundal height equals day PP; F involutes

about 2 cm everyday PP)
● Location of uterus = midline (if not midline it means the bladder is
distended → need to cath)
○Bladder
○Bowel
○Lochia (vaginal drainage) PP*** know the order
■ Rubra (R for red) = Red
■ Serose (semi red) = pink
■ Alba (albino) = white
■ Moderate amount: 4~6 inch on pad/hr
■ Excessive amount: saturates in 15 mins
○ Episiotomy (check for incision)
○ Hemoglobin/hematocrit
○ Extremities*** looking for ‘thrombophlebitis’
■ Thrombophlebitis: inflammation that causes an blood clot in legs (e..g, DVT) – pain,
swell, tender, warm, restlessness on extremities
■ What is the best way to determine if a pt has thrombophlebitis? MEASURE
BILATERAL CALF Circumference (homan sign is not the best answer here)
○ A ect - emotion
○ Discomforts
● Make sure you focus on the 3 designated steps stated as important from BUBBLE HEAD

Variations in the newborns

✦ Review all normals and know the di erence between Caput succedaneum vs cephalohematoma
✦ know the di erence between physiological jaundice and pathologic jaundice

Normal skin conditions

● 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 neonatorum
○ Described as flea-bitten lesion … pink rash with firm, yellow-white papules or pustules 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 a ect 10% of all children
● Vernix caseosa

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○ 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: seen at birth, found on the face and neck, red to purple, does not blanch on
pressure

Cephalohematoma vs. Caput succedaneum (CS)

○ Cephalohematoma: collection of blood between the periosteum of a skull bone and
a bone itself
■ Occurs in one or both sides of head, occasionally forms over the occipital bone,
develops within the first 24~48hrs after birth
○ Caput succedaneum: edema of the scalp of the neonate during birth from mechanical
trauma of the initial portion of scalp pushing through a narrowed cervix
■ Edema crosses the suture lines
■ May involve wide areas of head or it may just be a size of a large egg
■ CS – Crosses Suture line, and Caput Symmetrical
■ Disappears without tx, no pathologic significance

● Hyperbilirubinemia
○ Physiological jaundice is normal and appears after 24 hrs after birth, disappears in
about a week
○ Pathologic jaundice is abnormal and is seen in the first 24 hrs after birth

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6 OB medications (3 kinds):
┖ Terbutaline, MgSO4, pit, methergine, dexamethasone, surfactant

1. Tocolytics: stops contractions/labor

● Terbutaline
○ S/E: Speeds up mom’s HR
● MgSO4
○ Induce hyper-mg which can cause everything to go DOWN
○ S/E: decreases HR, BP, Reflexes, RR, LOC
*** What is the nursing intervention for hypermagnesemia due to mgso4 tx?
● Monitor RR: if <12, decrease the dose of MgSO4
● Assess Reflexes: normal reflex is 2+, if 0 or 1+ → decrease dose, if 3+ or 4+ increase dose

2. Oxytocic: stimulates and strengthen labor

● Oxytocin
○ S/E: uterine hyperstimulation (defined as longer than 90 secs, closer than 2 mins) →
nurse should lower the dose in case of uterine hyperstimulation
● Methergine
○ S/E: causes HTN, if it contracts blood vessels it makes sense that this increases BP

3. Fetal/neonatal lung meds: given to mature baby lungs faster

● Betamethasone (steroid)
○ Given to mom IM before birth
○ Can repeat as long as baby is in utero
○ S/E: increases glucose (steroid)
● Surfactant
○ Given to baby after birth
○ Via transtracheal route

Medication helps and hints

What is Humalin 70/30?
● Mix of insulin N and R: 70%N, 30% R (NPH, Regular)
● 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 u of N and 15 u of R
● N in numerator, 70

Can you mix insulin in the same syringe and how?

● Yes, insulin can be mixed in the same syringe
● How? “NRRN” – pressurize then draw up
○ 1. Draw up total dose of AIR
○ 2. Pressurize the “N” vial (put air in it)
○ 3. Pressurize the “R” vial
○ 4. Draw up “R” dose
○ 5. Draw up “N” dose

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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 “1”
○ 21 G, 1-inch needle
● Giving a SQ injection
○ 5 looks like an “S” in SQ
○ Pick answers that has “5” in it
○ 25 G, 0.5-inch needle

Heparin vs. Warfarin***

Heparin Warfarin (Coumadin)
● Give IV or SQ ● ONLY PO
● Works immediately ● Takes few days to a week to work (likely
● Cannot be given for more than 3 wks 4 to 5)
(except for levonox/enoxaparin – can ● Can be on it for lifelong
be given longer) ● Antidote: Vit K
● After 21 days the body start making ● Labs: PT/INR
antibodies against heparin ● Can’t be used during pregnancy – class
(life-threatening). Therefore it is NOT X med
given for more than 21 days (Only antipsychotic that can be given to
● Antidote: PROTAMINE SULFATE pregnant women is haldol)
● Labs: PTT
● Can be used during pregnancy – class C
med

Diuretics
● K-wasting vs. K-sparing diuretics
● Any diuretics ending in “X”, “mides”, and Diuril, eXit out K – so it wastes “K” like LasiX
● If it does not end in “X”, is spares K
● E.g., Lasix (furosemide), Bumex (bumetanide), Clotrix, Diuril (chlorothiazole),
hydrochlorothiazide = K wasting
● E.g., Spinorolactone, amiloride, triamterene = K sparing

Baclofen (Lioresal) and Cyclobenzaprine (Flexeril)

● 2 muscle relaxants to know for NCLEX
● 2 S/E’s:
○ Fatigue/drowsiness
○ Muscle weakness (paresis)
● 3 things to teach:
○ Don’t drink
○ Don’t drive
○ Don’t operate heavy machinery

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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
● Make sure not to confuse these two!
1. Sensorimotor (0~2 yr)
● They only think about what they are sensing right now
● You can teach only in “present” tense
● Just tell them in present tense,
● They don’t understand play, tell them as it is happening
e.g., a 19 month infant is about to have LP for CSF analysis and culture how do you teach the child?
Tell the child how LP is done while it is being done, there is no such thing as preop teaching at this
age. Preop teaching is only for parents.

2. Pre-operational (3~6 yo)

● They are fantasy-oriented, imaginative, and illogical – their thinking obeys no rules
● However they understand Past and Future tenses
e.g., 3 yo child is scheduled for LP how do you teach about the procedure? Teach 2 hrs before,,, the
morning of,,, the day of ,,, how it will be done, don’t give them whole lot of time for imagining the
worst, teach them what will be done (future), they can learn by playing

3. Concrete operational (7~11 yo)

● “7/11 grocery stores are surrounded by concrete” – no trees, no flowers
● Children in this age group are “rule-oriented” they cannot abstract
● There is one way to do things. Everything else is wrong
● Teach them a day/two ahead, teach them what you are going to do and how to do skills
● Use age-appropriate reading and demonstration skills
e.g., 8 yo scheduled for LP how do you teach? use age- appropriate demonstration 1 or 2 days before
the procedure

4. Formal operational (12~15 yo)

● Can ABSTRACT and think CAUSE AND EFFECTS
● As soon as children become 12 teach them like an adult – not it’s med-surg question
● When is the first age a child can manage his care? 12 yo (manage means making decisions
which require the person to abstract)

☁ Questions ☁
Q. Which of the following will be able to manage his own care?
1. A 7-yo with cystic fibrosis
2. An 8-yo with DM
3. A 10-yo with a scraped knee
4. A 13-yo with CRF

Answer) 4: MANAGE means that knowing what you can do when you can and seek for
help when you cannot

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✴ NCLEX Tips ✴
● So when it says MANAGE = 12 yo, when they say SKILL, 7 yo

7 Principles to OBEY when taking Psychiatric tests

1. Make sure you know what phase of the nurse-patient relationship you are in

2. Don’t give/accept gifts in psych

- if pt is schizophrenic, giving flowers could mean proposal

3. Don’t give advice!!!

● If pt says “what do you think I should do?”, reply back by asking them the same
question - “what do you think you should do?”

4. Never give guarantees

● e.g. don’t say things like “if you cry you will feel better” – don’t say “IF YOU ___ YOU
WILL ___”

5. Immediacy
● If you are between two answers and you don’t know which one to pick, pick the one
that Keep pt talking
● Don’t refer to someone

6. Concreteness
● Psych pts take you literally. Therefore, NEVER USE SLANG
● Don’t ever say to an upset pt to “chill out”
● Don’t use figurative speech such as “what goes around comes around”

7. Empathy = acknowledging feeling

● Empathy is about the nurse accepting the pt’s feeling
● Don’t ever pick an answer that says “don’t you worry… ” “you shouldn’t feel … ”
“anybody would feel ”I know how you feel … “
● Rather say, “that’s so upsetting … “

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

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LECTURE 12

4 Rules for prioritization

1. Acute > chronic
2. Fresh post op (12hrs) > acute/chronic medical/surgical
3. Unstable > stable
○ Unstable patients: “unstable, acute illness, post op <12hrs, general anesthesia in the first
12 hrs, lab abnormalities in C/D levels – e.g., INR in 4s, K in 6s, pH in 6s,CO2 in 50s, low o2
sat, high WBC, low ANC, low CD4, low platelets” “newly diagnosed, newly admitted, not
ready for d/c, admitted <24hrs, changing or changed assessment, experiencing
unexpected S/Sx”
○ Stable patients: “stable, chronic illness, post op > 12hrs, local or regional anesthesia, lab
abnormalities in A and B levels – Cr, BUN, Hg 8-11, Bicarb, elevated Hct, elevated BNP,
elevated Na, RBCs o ” “ready for D/C, to be d/c’d, unchanged assessment, experiencing
the typical expected S/Sx of the disease with which they were dx’d“
○ 4 things that always make you unstable even if they are expected:
■ Hemorrhage but not bleeding
■ High fever over 40 deg C – can lead to seizure
■ Hypoglycemia – can lead to brain damage
■ Pulseless or breathless – e.g., 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 lower priority)

In a mass casualty incident, these 3 things result in a BLACK TAG

1. Pulseless
2. Breathless
3. Fixed and dilated pupils (even if they are still breathing )
“tag them black and ship them last”.

4. Tie breaker rule

If the above 3 result in a tie breaker, use the following as a guide:
■ The more vital the organ, the higher the priority
■ Brain > lung > heart > liver> kidney > pancreas
■ Use this rule with the organ of the modifying phrase and NOT the dx
Examples:
a. You have 23 yo male, with CHF, WITH k 6.6, no EKG changes
■ Chronic (low)/ 6.6 (high)/ no changes (low)
b. CKD with Cr 24.7, pink, frothy sputum
■ Chronic (low)/ Cr expected (low)/ pink frothy sputum -not expected (high)
c. Acute hepatitis, jaundice, increased ammonia, you cannot arouse
■ Acute (high)/ expected s,s (low)/ unexpected finding (high – brain)
■ So, c is more priority than the other two

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Delegation of Responsibility

RN LPN UAP
● First of anything ● IV: Can ONLY maintain an IV and ● ADL
● Judgement document the flow ● Hygiene
● Education ● CAN implement care plan but ● Linen
● Assessment cannot make them ● Routine and stable VS
● Analysis ● Monitoring, reinforcing, routine ● Collecting and
● Critical thoughts workups, ostomy, specific Document I and O
● Nursing process – assessments ● Sugar check for DM
assess, dx, planning, ● Stable pts ● Positioning (passive
intervention, evaluation ● Routine procedures – and active ROM)
● Accountable for care by catherization, meds (except IV), ● Nothing about nursing
UAP ostomy care, enteral feeding, tube process
patency, nasotracheal suctioning,
nasogastric tube insertion, drsg
changes, subq, IM, oral meds
● Nothing about nursing process

New graduate
● Stable patients

LPN CANNOT do following:

● Cannot start an IV
● Cannot hang/ or mix IV meds
● Cannot Push IV meds
● Cannot administer blood or deal with central lines – including flush, changing drsgs
● Cannot make the care plan – they can implement the care plan
● Cannot perform or develop teaching – they can only reinforce teaching
● Cannot take care of unstable pts
● Cannot perform the “first” of anything – includes careplan, assessment, drsgs, ambulating,
post op v/s obtaining.
● Cannot assess: admission/ DC/ transfer/ first assessment after a change has occurred

UAP CANNOT do following:

● Charting – can only chart WHAT THEY DID but they cannot chart about the pt.
○ E.g., they can write “side rail is up, bed is lowered” but cannot write “pt less anxious,
tolerated, ambulated well”
○ Can only write what they did to help pt, cannot write anything that they assessed about
the pt
● Medication administration – except for topical, OTC (A&D), barrier creams
○ They cannot give nitroglycerin/ Neosporin ointments (hydrocortisone cream) cuz they
are not OTC drugs
● Assessment – except for vitals or accu check for DM
● Treatment – except for enemas

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● RN can delegate ADL tasks to a UAP

● BUT UAP should NEVER do any ADL task first

What to and NOT TO DELEGATE to the family members/ friends of pts

● Never delegate them safety responsibilities. For instance, if they ask/tell RN about things to do
while RN is away, you cannot delegate safety responsibility to them.
● RN cannot delegate safety to a non-hospital caregiver unless the person is trained (such as
seater) on how to do the tasks. In this case, RN must document in the pt’s record what exactly
was taught
● E.g., can mom give insulin shots to her 3 yo child? – yes, if you teach her and documented
teaching
● What if a new mom asks the RN to “leave the railing of my baby’s crib down and I will put it back
up after I finish bathing my baby. You can go about your business” → RN’s should say something
like “don’t worry about me leaving, I will stay with you until you are done” – the point here is YOU
RN SEES the rail goes up before you leave the room. You should not delegate this safety
responsibility to family.

Staff management
How do you intervene with inappropriate behavior from staff?
● This is not prioritizing nor delegating
● This is handling sta members who did stupid things
● There are always 4 answers:
○ Tell supervisor
○ Confront them and take over the task the sta is implementing immediately
○ Talk to them later
○ Ignore it (NEVER IGNORE inappropriate behaviors! You should use the incident as an
opportunity to teach and change behavior – So, this is wrong answer)
● Choosing among the first three options depends on the nature of the incident
○ Is sta doing something illegal?
■ If yes, tell supervisor
■ If No, ask yourself if anyone is in immediate physical or psychological harm
● If yes, confront immediately and take over
● If no one is in harm’s ways, ask yourself if this behavior is simply inappropriate
○ If yes, talk to that particular sta at a later time about the incident
■ If the illegal act can be also harmful to the pt, confront it and take over the task now
first and then report it to supervisor

☁ Questions ☁
● You suspect the RN is diverting narcotics.
o Tell Supervisor
● The Aide is giving perineal care to pt, not wearing gloves?
o Confront and take over the task
● The RN is going home with bulging pockets?
o Tell Supervisor

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● You notice the surgeon contaminates her gloves?

o Confront
● The RN always gives reports, always says exasperation instead of
exacerbation.
o Talk to them later
● If an illegal act can be harmful to the pt …
o first, takeover the task and then report the incident to supervisor
● If 2 pts are having sex, or a pt is masturbating what do you do?
o Shut the door and give them privacy

Organ location (know the organ locations)

Auscultating over heart valves

● When answering questions to identify heart valves, you must click exactly
over a narrow area to mimic stethoscope placement. The areas
auscultation for murmurs (or sounds) are remembered by “A PET M”

1. The Aortic valve is located in the 2nd intercostal space, right of the
sternal border
2. The Pulmonic valve is located in the 2nd intercostal space, left of the
sternal border

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3. The Erb point is rarely asked on the exam; It is located in the 3rd intercostal space, left of the sternal
border; between the pulmonic and the tricuspid valve
4. The Tricuspid valve is located in the 4th intercostal space, left of the sternal border
5. 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)

Brain Anatomy

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Lungs Anatomy

Kidneys Anatomy

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Guessing strategies
┕ Use these tips when all the answers don’t make sense
● Psych questions: best answer is “the nurse will examine their own feelings about…” to prevent
countertransference. Another is “Establish a trusting relationship”.
● Nutrition questions: in a tie, pick chicken (unless it’s fried), if chicken’s not there pick fish (not shellfish).
Also never pick casseroles for children. Never mix meds in children’s food. For toddlers choose finger
foods. Preschoolers leave them alone, one meal a day is okay.
● Pharmacology questions: Memorize side e ects of drugs. If you know what a drug does but you don’t
know the side e ects, pick a side e ect in the same body system where the drug is working (i.e: GI drug
pick diarrhea or a CNS drug pick drowsiness etc…). If you don’t know what the drug is look to see if it’s
PO pick a GI side e ect (works about 50/50). Never tell a child medicine is candy.
● OB questions: check fetal heart rate.
● Med Surg questions: LOC over airway on assessments, but the first thing you do should be establish
airway.
● Pediatric Growth and Development questions-
○ 3 Rules based on the principle:
○ (6 year old who can’t read, 14 mo. can’t walk, 6mo. trying to roll over v.s. sitting up)
○ Always give the child more time, don’t rush their growth and development
■ Rule 1: When in doubt call it normal
■ Rule 2: When in doubt pick the older age
■ Rule 3: When in doubt pick the easier task
● Rule out generalized absolutes if you’re guessing
○ If two answers say the same thing, neither of them is right
○ If two answers are opposite, one of them is probably right
○ The “umbrella strategy”: look for an answer that covers all the others without saying it does (i.e:
use safety and good body mechanics when transferring a patient from bed to wheelchair)
● If the question gives you four right answers and the question is asking for prioritization, use the rules
above, however if they give you one patient in the question and it asks “which needs is highest priority”
don’t use it! Do the worst consequence game. Choose the answer with the most severe consequence.
● When you’re stuck between two answers, re-read the question
● The Sesame Street Rule: (use as a last resort) Right answers tend to be di erent then the others
because it is the only one which is right so the other “wrong” answers have something in common
● Don’t be tempted to answer a question based on your ignorance instead of your knowledge. Pull the
“thing” you don’t know out of the question and answer it with the things you know. Boards will give you
things you never heard of to measure your common sense
● If something really seems right, it probably is. DON’T go against your gut
● Answer unless you can prove why the other is superior
● Select all = Now it can be just one or all of them (NEW)
● Conflicts on the job: never say you. Always say “I”
● Headache is a good thing to check on SATA!
● NEVER PICK INFECTION IN FIRST 72 HRS of anything!

3 Expectations CAN’T HAVE because they cause negativity:

● Rule #1*: Don’t expect 75 questions, prepare to get all 265 questions. “I’m still in the game”.
● Rule #2: Don’t expect to know everything.
● Rule #3: Don’t expect everything to go right.

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