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NCLEX Review Notes Mark Klimek Lectures - Document preview page 1

NCLEX Review Notes Mark Klimek Lectures - Page 1

Document preview content for NCLEX Review Notes Mark Klimek Lectures

NCLEX Review Notes Mark Klimek Lectures

Lecture on acid-base balance and ventilator interpretation for NCLEX prep. Covers pH, CO₂, HCO₃ values, metabolic vs. respiratory disorders, and the "Rule of the Bs" to simplify diagnosis—ideal for nursing students and critical care review.

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NCLEX Review Notes Mark Klimek Lectures - Page 1 preview imageMARKKUAliKLECTURESNCLEXREVIEW NOTES
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NCLEX Review Notes Mark Klimek Lectures - Page 2 preview imageTzab’le of ContentsL e c t u r e 1 -Acid-ase Palance, VentilatorsLecture 2 - Alcohol, Wernicke, Overdose and Withdrawal S/Sx, Aminoglycosides,Peakand 1 roughL e c t u r e 3 -cardiac Medication, Calcium Channel plockers, Cardiac Arrhythmias,Chest 2 ubc, Congenital heart Pefects, Infectious Pisease, PTELecture 4- - Crutches, Canes, Walkers,Petusions,hallucinations, Psychosis,Psychoticand Non-Psythotic hallucination,Illusion, PelusionL e c t u r e 5 -Piabetes Mellitus, Piabetes Insipidus SlAPh, Insulin, PKA, h h N KL e c t u r e(a -Prug Toxicities (Lithium, Lanoxin,P itantin, pilirubin, AminophyIline),Kernic+eras, Pumping /Electrolytes: K+, LA, W£?|, and NA, Treatment for■hyperkalemia.L e c t u r e 7 -Thyroid (-hyper-, hyp*-), Adrenal Cortex (Addison Pisease, Cushing),Toys, LaminectomyL e c t u r eLabValues, five Voadty Ps, Keutropenif PreMU-tiovi.L e c t u r e-Psych Pru s, 7 ri, Peni o , WAAOI, Lithium, protac, hldol, Clotaril,£oloftL e c t u r e-Maternity and Neona tologyL e c t u r e H- petal Complications, Stages of Labor, Assessments, Variations forNp, Maternity Medications, Medication hints, Psych Tips, Operational Stages.L e c t u r e 1 2-Prioritisation,P elegation, Staff Management, guessing Stra tegies
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NCLEX Review Notes Mark Klimek Lectures - Page 3 preview imageNURSINGE X A MSUCCESS
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NCLEX Review Notes Mark Klimek Lectures - Page 4 preview imageK.J<?4 t?JldS3J S i 4-1'2SIAAJ3144-O9I | o q174-3 1 S I 37MV]t?£|Uil 3St?£J)-pi7k? 3144- 113144 ' l W i 4 - 3 3 J i p 3 H W S 34- I‘.I 144-03A0lU c5|Jk77l£L |?UP fjd} J:S<3. 9 L | 4} o3 ’ L ? >fp4 144-1:A 11914 J 3 J i p 9 4 lS<7d49 JO 3lAk?S 3 L- HI S 3 0 &J3I443I41A 3111LMJ 3 4-3'i? 'hjC?4-t7JldS3J JO 7l|<7<4t?4-3U1 S i 33llt?]K’tf|lUI 3S]4- } l3H11HIJ 34-33 04- 'MP|M4-d37X3 '6 lb] S I &Ull44-hj9A9 'I461I4 S i fri-}J-m w i S S P 4 a d 4-d37X3 'iAqSi GHib|4-hj3A3S i ffdJ-J -SMP3UA 4-L714.|_ "■U3MlSSt?+0j. JQJ. 4-437X3 '4-U3l-|-Vd hl*l S 3 9 & OS 'S3Cj6d3l|4- StfSIs o p pt? hjQ4-t?JldS3J -j-o 3 | d u i P X 3Ht? S I S1L|X "hjo+*7J»dS3y_ G'r £(Z?|d "SisopuyZ Z ' L-£ # 3|duit?xaSISQ|IZ4|17t?4-3H I J-0 3|dlUPX3Ht? S i SlLj J_ -71)0/5]t?4-9W7f+ -714-O]isqpy91-3 | d l M t ? X ' dSIS0WI717 7 i pt?4-3lM 4 0 3 | 4 m t ? X 3Ht? S i S1I4J_ -7lfOt?4-3O Et O O H ”S i s o p i j y£ ’ £ffd-V-# 3 | d H l t ? X ' i■-■?;.'■i■■.'■S I 37Ut7|l7i5|U4l 3St?3]-pi7t? 2I44-4 r £ <S i f-pi -J-J -7I4-Opi7t? S i 37Ut?|E?i l?JI 3St?iJ|-piJt7 3b|4 ' £ £ £ >S i f-|-i-3144-S l JSJUJQSlp 3St?- p i 7 V Ht? HI 4-t?OO] 04. 3W|t?A 4-SJL} 314J_,(i?4-i5rMcwyt77k4)£<X>ftput?ZCO'ffd-<o} S3W]t?A |t?u4jow 3144-iVLQtt04- 4-hP+Jodtwi Si 41. ' s j s p j o s i y ? 3S(7-ppt? 3A|0S <?_L3?Llt?Jl?<A. ?SL7. / p i 3S J 0 4 I?114 ?.3.A ' 3 JU1711?&3 S t ? < 4 . - p i 7 VVSVg p»3yPH:----------- 7.35 -7.45PACO; ---------- 35 -45HCOj ----------- 2 2 - 2 6PAO;----------- 8 0 -10002SAT-------- > 95%
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NCLEX Review Notes Mark Klimek Lectures - Page 5 preview imageI fp Hoes over 7 . 4 5 , t h i s i s alkalosisTherefore, everything is IXF: tachycardia, tachypnea, f H N, seizures, irritability,spastic, diarrhea, borborygmi [increase bowel sounds), hyperreflexia (3+, 4+)However, potassium i s low (opposite). Therefore, Hypokalemia- What i s t h e nursing intervention?L- p t need suctioning because o f seizuresH■4.I fp H goes below 7 - 3 5 , t h i s i s acidosisTherefore,, everythi115 is PC*WN: bradycardia, constipation, absent bowel sounds,flaccid, obtunded, lethargy, coma hyporeflexia (0, V), bradypnea, low Pt.-flowever, potassium is h i g h . T h e r e f o r e , Hyperkalemia- What i s the nursing intervention?- patient needs t o be ventilated with an Ambu bag—respiratory arrest!So, remember that"MAC Kussmaul " jc.-phe only acid~base imbalance t o causeMetabolic ACidosis with Kussmaul respirations.Causes o f A c i d / l ase imbalance:f i r s t ask yourself, "Is it LU.N? . . . I f yes, then iti s respiratoryThen ask yourself, "Are they o v e r v e n t i l a t i n g o ru n d e r v e n t i l a t i n g ?- I fUHPffRventilating, then pick acidosis—pH i sunder 7 - 3 5- I fOVVentilating, t h e n i t i s alkalosis, p-H isover 7 . 4 5IF I T I S LUNGS* RESPIRATORYUNOERucntiloting* Ac idosisOVERuenukiting -What type of acid-base derangement is present in t h e following condition?I nl a b o r ?-"Respiratory alkalosisCverventilatincj—p7 increasesAlkalosisP r o w n i n?-"Respiratory acidosisUndervenHIatin—p H decreases... AcidosisP t is on P'CA (patient-controlled anesthesia) pump?- Ventilation is down ..."Respiratory acidosisI fit is n o t LUN61, t h e n i t is metabolic. I ft h e p a t i e n t h a s prolonged gastricVomiting or suction (sucking out acid), pick alkalosis.
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NCLEX Review Notes Mark Klimek Lectures - Page 6 preview image- Tor everything else that isn't lung <pick metabolic acidosis- So, when youdon't know what t o pick. pick metabolic acidosisT i p- Set your default setting t o Metabolic ftcidosis- Always pay attention t o modifying phrase rather than original noumV e n t i l a t o rft Ventilator is a machine designed t o movebreathable air into and out of t h e kings,aids patients who are physically unable t obreathe, or breathing insufficiently t obreatheft Ventilator is equipped with ahigh and a low-pressure alarm,■High pressures alarms are always triggeredby increased resistance t o air flow. Look forobstructions:- Kinks in tubing ...Solution: unkink the tube- Condensed water in the dependent tube...Solution: empty it- Mucus plugs ...Solution: Ask patient t oturn, tough, deep breathe; or suction t h etubing TRNWhat is the appropriate order t o address high pressure alarm in a mechanicalVentilator?Cl) Unkink.(2.jEmpbJ water out of tubing. ( 3 ) turn pt, ask p t t o cough or deeplybreathe, and f4) suctionLow pressures alarms are always triggered bdecrease in resistance. This can becaused b
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NCLEX Review Notes Mark Klimek Lectures - Page 7 preview image- Main tubing disconnection- 0 2 . sensor tube disconnection- I n both cases, reconnect the disconnected twbing unless tube is on floor „.t>ag p +and call'Respiratory TherapistThe ven tilator may be set too high or too lowSetting is too high ... Tatient is over -ventilated-’Respiratory Alkalosis ... TankingSetting is too low ... Tatient i s tinder -Ventilated-’Respiratory Acidosis ... "Patient i s retaining 0 0 2QuestionThe physician wants t o wean patient off v e n t in the morning. A t G>am, the A’ (5|Ssay respiratory acidosis. What would you do next?Notify the physician thatthe patient is not ready t o be weaned off the respirator- T t is in respiratory acidosis, which means that he is underventilatedTherefore,not ready t o be weaned off t h e ventilator.- I fpatient were in respiratory alkalosis (overventilated), he should be ready t o beweaned off,
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NCLEX Review Notes Mark Klimek Lectures - Page 8 preview imageLecture 2Alcohol, Wernicke, Overdose and Withdrawal S/Sx, Aminoglycosides, Teak and 7 roughAlcoholismNo be: T h e title o f t h i s section is alcoholism. -However, thisrule can be used for any abuse situation- So, w h a t it the number 1 psychological problem in childabuse? ... Tn gambling?... I ncocaine abuse? ...I n spou salabuse? ... I n elder abuse?T h e a n s w e r i s denialT h e # 1 psychological problem is P EM l AL■How do you respond/treat t o pts in denial?- Confront them by pointing out the difference b/w what they say and what they do- for instance, say something like:,rOk, you say you're not an alcoholic, but it is 1 0a.m. and you've already had a(ppack" ...I tis not the same as aggression.Pon'tattack t h e person- (Stood answer has " I " ...Pad answer has "VOU"- One place where denial is ok—foss and grief S tages o f grief are " P A P PA " - Penial,a n g e r , b a r g a i n i n g , depression, acceptance- So when the question is about patient in denial, pay attention t o whether you aredealing with loss or abusive situationS u p p o r t - L o s sC o n f r o n t -Abuse4t !P ependency v s Co-dependencyT h e # 2 psychological problem is Pependency or Co-PependencyPependency; when the g e t the significant o t h e r t o do things or make decisions forthem- T h e abuser is dependentCo-dependency: when t h e significant other derive self-esteem for doing things ormaking decisions for the abuser- The significant other is the co-dependentPependency and co-dependency have a symbiotic, yet a pathological relationship- T h e dependent patient gets a free ride on the co-dependent- T h e co-defendant patient feels good from "doing stuff" for the abuser
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NCLEX Review Notes Mark Klimek Lectures - Page 9 preview image-Mow do you treatdependency/codependency?- dependent pts are "abusers"Confront them- Co-depe»ident pts have self-esteem issues „. Teach pts how t o set limits andenforce them- flgree in advance on what requests are allowed -then enforce- Teach significant other t o say N O- Work on self-esteem on the co-dependent personM a n i p u l a t i o nManipulation is when the abuser gets the significant other t o do things or makedecisions thatare not in the best interests o f the significant other- The nature o f the act is dangerous and harmful t o the significant otherMow i s manipulation like dependency?- I n both situations the dependent person gets the co-dependent person t o dothings or make decisions- I fwhat the significant o t h e r is being asked t o do i s not inherently dangerous andharmful, t h e n this is dependency/co-dependency- Mowever, i f the significant other i s being asked t o do something inherentlydangerous and harmful, then this i s manipulationManipulation? Set LIMITSand Enforce themExamplesPetermine i f either one of these situations is dependent/co-dependent problem or amanipulation problem* 4-year-old alcoholic gets her 17-year-old son t o go t o the store and buy alcoholfor her.- The mother is manipulating the son- This is an illegal act - harmful- dependency ... There are 2 patients- T h e dependent has a denial issue- The co-dependent has a self-esteem issue• ft 4-year-old alcoholic asks her 60-year-old husband t o go t o the store and buyalcohol for her.- This is not illegal for the husband t o buy alcohol- T h i s a dependency/co-dependency situation- Manipulation ... There i s 1 patient— no self-esteem issues
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NCLEX Review Notes Mark Klimek Lectures - Page 10 preview image- Easier t o treatno one like -to tee man!pulatedWernicke ( K o r s a k o f f ) SyndromeTypically, Wernicke and Korsakoff are 2 separate disorders. T h e NCLEX howeverbundles the 2 a s 1 CondiHon- Wernicke is an encephalopathy- Korsakoff is a psychosis- Wernicke and Korsakoff tend -to go togetherWernicke and Korsafoff- Psychosis induced by Vitamin th, thiamine deficiency- T h i s is a situation the patient loses touch with reality due t o vit T h deficiency- The primary S/Sx are amnesia (memory loss) and confabulation (making u p stories)Confabulation—T h e lies for this pts are just as real as realityvJow do deal with a patient w i t h Wernicke and Korsakoff who is confabulating aboutgoing t o a meeting with T arack Obama this morning?-'Redirect the patient t o something he can do- for instance, tel! patient something along that line: "Why can we go watch T V t osee what is on the news today”Characteristics of Wernicke and Korsakoff syndrome1. Preventable ... Take T h2 .Arrestable (stop i t from getting worseJ ... Take PT3 . Irreversible (70o)Will kill brain cellsA n t a b u s e and R e v i a (Pis u l f i r a m )A n t a b u s e —Alcohol deterrent"Revi a —Aliti dote-Aversion (strong hatred) Therapy —a type of behavior therapydesigned t o make a patient give u p an cmdesirable habit bycausing t h e m t o associate it with an unpleasant effect- Works in theory better t h a n in realityOnset (how long it takes t o startworking) and duration (how< long it lasts) ofeffectiveness of A tabuse/Revia i s 2 weeks- for instance, i f patient will be a t a function and would like t o drink, t h e p t must beon Antabuse /Revia a t least 2 weeks prior t o the event
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NCLEX Review Notes Mark Klimek Lectures - Page 11 preview imagep a t i e n t t e a c h i n g- Teach patient t o avoid all forms o f EtO{4. Mot doing so malead t o symptoms ofvi!\fteven death- Teach them t o avoidkhe followings items a s theu contain alcohol ... Mouth wash,cologne,perfume, aftershave, elixir, most O T C liguid medicine, insect repellavit, handsanitizer, vanilla extract (can't have cupcake with unbaked icing)- On t h e exam, do not pick the"Red Wine Vinaigrettes . . . I t does not have alcohol in i tOverdose and W i t h d r a w a l"First thing <(ou ask in an overdose guestion is: I sit an Upper or a Powner?- 7 his is because everq abuse drug is either an Upper or a "Uowner- 7Jowever, laxative abuse ivi the elderly is neither an Upper nor a Vowner* CaFTlrt- _ocaii t■I'/LSP (psi cdc iws/halktfinogenrtV. KL-.r; p r h ibniwc..- Pddc'at o r <r.t h f j f".Vr ’-v' "lirNi'Li. XUPPERDOWNER- 'Hficr'c Art oVCt 1 3 5 dr<*g$ thai- are swwrtr'S- ZT't--1a n >. - p a .-. . a div. iLi. i.’.ipt"■- T , - i n g :j PCv. I1_ r thfl<" r " . ]■. I T M 4 Jr r lt . ./' I I • . r.ccHStiprt+tsl, etc‘in. -1’ J+rn'r..- '"I-’ ngs go u -■Euphoria, seixitres,IrritaWftty.1-1pcrrc fit :«J.a7 - . 4 4 . rac'.T •■. r dia, 1. cre■£<■?.■ewerorbo'■■-i.r■. . r •-!-€.•What is the highest nursing priority t o anticipate in an Upper or downer?- Upper; T h e highest priority t o anticipate in an Upper is suctioning due t o seizures.- 'Powner: The highest priority t o anticipate in a 'Powner is intubation/ventilationdue t o respiratory arrest.ExampleOne of t|our patients is "high on cocaine." what is critical'important t o assess?
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NCLEX Review Notes Mark Klimek Lectures - Page 12 preview image- fjavina T R o f 1 2 is notacritical measurement t o assess for that patient- {Jowever. assessing for reflexes ( 3 + or 4+j, irritability borborycjmi increased bowelsounds), or increased temperature wowId be more appropriate- T h e W Crale" does not apply hereI n fact, the patient's ACin cocaine toxicityis unremarkableft-fter you know -that -the druin question i s an Upper or a Powner, -the secondquestion you should ask yourself i s whether i t i s an Overdose or a Withdrawal?- Overdose and withdrawal have the opposite effectsOVERDOSEOventMOverdose o*i a n UpperCVercose on a TownerTooinuctToo I'H-rle'/■Jit.vrav,/Wit, arawon a> Uopei- Tool i t t l e.■jitkvi .:wa. on a p o wa- T o o ' r n c hQuestionThe driver of a squad car calls the P T and says he is brinejinej a p t who in Oped oncocaine. What do you expect t o see? ... Select all -that applypatient OPed on Upper O P ... Expert -to see T 00 much- firstquestion: Upper or a Powner?- Second question: Overdose or Withdrawal?- S/SX would be: Irritability4 + reflexes, borborvfcjmi, increased temperature, etc.QuestionThe same patient is withdrawing from cocaineSame question- This patient is an Upper in Withdrawal - Too little- Therefore, respiratory is under 1 2 , patient is difficult t o arouse, cjive t h e m Marcan
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NCLEX Review Notes Mark Klimek Lectures - Page 13 preview imagePrue) flbwse i n t h e NewbornAlways assume intoxication, not withdrawal a t birth, in a newborn less than 2 4hours after birth, 2.4 hours or 'more after birth, youn assume the newborn is inwithdrawalQuestion7ou are caring for an infant born -to Quaaiude addicted mother 2 4 hours after bir th.Select all -tha t applyOverdose/withdrawal condition ,.. Ask t h e following 2 questions- I s it an Upper or a Powner?We don't what i t is because i t is a "Quaaiude" (it islikely a Towner)- I si t Overdose or withdrawal? ... 2 4 hours a f t e r birth (Withdrawal)- fl Towner in Withdrawal - Too much- S/Sx - Pifficult t o console, seizure risk, shrill, hi h-pitched cry, exaggerated startlereflexAlcohol W i t h d r a w a l Syndrome v s . P e l i r i u m T r e m e n sAlcohol Withdrawal Syndrome and Pelirium 1 remens are not the same- Every alcoholic cjoes through alcohol withdrawal approximately 2.4 hours after theperson stops drinking- however, less than 2 0of alcoholics in alcohol withdrawal syndrome progress t odelirium tremens...Pelirium tremens occurs about 72. hours after the person stopdrinking,- Alcohol withdrawal syndrome always precedes delirium tremens; however, deliriumtremens does not always follow alcohol withdrawal syndromeAlcohol Withdrawal Syndrom*. n■. , -+ti. -4 iDiir. iHc- /1idH*)MOMI *'< i H ' c m v r i i Q i tjs’iidotirttnL'JlAti'J!TJ. L _- Flcu;<'.*r J'bM- Sr'iTi'T- r /i-lv I■"JL (HVIJ A Z l c T f .‘-u t/|c, u>-•i ;i ;i dilu■ii :n■■i .■,. ' K - ' .. i ..'.iJ e tCt'Jfjrio rr-:.*rdintsDelirium Trem«n«■O f f :■. . A c r, I t -■' . . T i t . T.■■itT.. -'i ici ' . r c f i t f. ]t o>xl‘. m J oT. : « i 'r.iI I . _■- J / i L!.1,Nr'l?i l i iC .C-ff . l■hl'..!J t-f_ - c v \ ..r w >| T.|,-Ifr-rlfj,■r+1H-llT,l-141■1i i d i■'.. i tI • ’'i i Mt r Ct1 ”■IOVC fMrlUfl.■s J f:i L ' —■■.6 i - r r i1Foer.u H-. |\Y". h o f2M f L l *lifter)
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NCLEX Review Notes Mark Klimek Lectures - Page 14 preview imageN o t e :- "Up ad lib" or "up a d liberum" means pat ient may have activity or free t o movearound as desired any time- 2-point lock le-tters restraints:Restraints. in 1 upper and the contrala-teral lowerextremit'es.Release and secure upper arm first, and then release and secure thefoot. Switch extremities every 2 hours- ffve both a n t i - f j T N medication, tran uiliter, multivitamin containing V'ffriQuestionSo w h a t two situations would respiratory arrest be a priority?- Overdose o f a Vowner- withdrawal of an UpperQuestionWhich pts would secure be a risk for?- Overdose o f an Upper- Withdrawal of a Pownersinc;!■<:L, es (Top 5 most t e s t e d d r u g s )Aminoglycosides are t h e big guns o f AbXs (antibiotics) —use them, when nothing elseworks. Aminoglycosides are unsafe a t toxic levels and safe ty then becomes an issue.7 hey are t h e 5th most tested drugs on the NCL£X“3 he m o s t t e s t e d d r u g s on t h e NCLfiX a r e ;T o p 5- Psychiatric- I nsulin- Anticoagulant- Pigitalis- AminoglycosidesO t h e r s- Steroids- "beta-blockers- Calcium channel blockers- pain medications- Obstetrics medications" A Mean Old Wlycin" - AminoglycosidesAMINOGLYCOSIPE TCJXKJTY
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NCLEX Review Notes Mark Klimek Lectures - Page 15 preview imageWould be used t o treat serious, resistant, life-threatening, ( ram negativesinfections.- So, treata mean old infection with a "Mean O l d Mycin"Examples are: TB, septic peritonitis, fulminating pyelonephritis, septic shock,infection from third degree wound covering >60of the body- fj owever, sinusitis, otitis media, bladder infection, viral pharyngitis, and strepthroat are not old mean infections and are not treated with a mean old mycinAll Aminoglycosides end in Mycin- ftentamycin, Vancomycin, and Clindamycin, Streptomycin, Cleomycin, Tobramycin- N o t all drags ending in mycin are aminoglycosides- Azithromycin, Clarithromycin, ErythromycinAll have TffRO in the middle ... So.TffRO t h e m o f f the " M e a n Old Mycin" list.W h a t a r e toxic e f f e c t s ?- Mycin—Sounds like Mice ( 7 hink ears) ... Monitorhearing (#7), balance, tinnitus (ringing of the ear,CN& toxicity)- T h e human ears are shaped like a kidney, so another<*#toxic effect of aminoglycosides is nephrotoxicity (Toxic t o the kidneys)Therefore, monitor Creatinine'What would be your answer i f in a guestion, you have t o choose which i s t h e bestbetween 2 4 - h o u r creatinine and serum creatinine?1. Creatinine - Best indicator of kidney function2 . 24-hour creatinine clearance is better t h a n Serum creatinineT h e figure 6 drawn inside t h e ear should remind you of 2 things:- They are toxic t o CNft- Administer them gft hourB o not give Mean Old Mycins TO because t h e y are not absorbed., and therefore wouldnot have any systemic effectsThere are 2 cases where Mean Old Mycins are given TO- hepatic encephalopathy (or hepatic coma) where ammonia level gets too h i g h- Tre-op bowel surgery: t o sterilise t h e bowel before surgery
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NCLEX Review Notes Mark Klimek Lectures - Page 16 preview imageI n both cases, the ftf&X stays in t h e gutno-t absorbed), sterilises the bowel.would not be -toxicandT h e # 1 a c t i o n o f a n " o r a l mycin" ,.. S t e r i l i s e -the bowel- Who can s t e r i l i s e my bowel?Neo Kan- Neomycin and Kanamycin'7": Mean Old V4ycin" is given I Mor I V because i t is excre ted in feces and n o tabsorbed in the 6|I tract. I tis used in hepa tic encephalopathy -to kill €. coli,.andbowel surgery (to sterilise -the bowel).No-tefL coli in -the gut is the # 1 producer o f ammonia, which a t -toxic levels,leads -to encephalopathyT r o u g h s and p e a k s- 7 r o u g h s is when drugs are a t their lowest concentration in the patient's blood- peaks is when drugs are a t t h e i r highest concentration in a patient's blood"Tft?"Levelsft method t o remember what is done before or after, when dealing with a medicationwith troughs and peaks, rf ftp " _ T rough, ftdminister, Peak- Trough before drug administration- Peak after drug administration- T rough and peak levels are drawn because o f a drug's narrow therapeutic windowor index- Narrow therapeutic window or index means that t h e r e is a small difference inw h a t works and what killsWhich one o f t h e following medications would "-trough and peak" important?* Lasix (furosemide)- Smaller dose: 5 or 1 0- Larger dose; ftO or 1 2 0* Pigitalis (digoxin)- Smaller dose; 0.12.6- Larger dose; 0-26
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NCLEX Review Notes Mark Klimek Lectures - Page 17 preview imageWould draw " T At" (Trough, Administer, peak) on digitalisN o t e : 'Draw T A T on Mean Old Mucins because o f t h e i r narrow therapeutic indejc.When t o P r a w a T h r o u g h and a P e a kToth Trough and Teak are not medication-dependentT h e trough, it is always drawn 3 0 minutes before next dosefor the peak, it depends on the route5 t o 1 0 minutes after drug is dissolved15 t o 3 D minutes after drug is finished (bag evnphjj3 D t o G?Dminutesi/ epends on insulin (See diabetes lecture)N o t necessary, not tested- teak Subb- teak I V- teak I M- teak SubQ- teak for TOQuestionVou give 1DD m b of a drug a t 2 00 m b per hour (the drug takes 3 0 minutes t o runJ.I fuou hang the drug a t 1 0 a.m., it will finish running a t 10:30 a.m. When will t h edrug peak?1. 10:15 a.m.2 . 1 0 : 3 0 a.m.3 - 1 0 : 4 5 a.m.4 . 11:00 a.m.Answer: T w o right answers—pick 11:00 a.m.I n this ease, platf the "trice IsT-ight" — go with the highest time w/o going overN o t eT h e same drug, given bn 2 different routes a t the same time will have differentpeaks- Morphinehowever, 2 different drugs given a t the same time and route (IV) will peaktogether- Morphine and amphetamine
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NCLEX Review Notes Mark Klimek Lectures - Page 18 preview imageN e g a t i v e chronotropydecrease rate of impulse formation a t theSA node -> decelerate heart rateN e g a t i v e dromotropydecrease speed that impulses from SAnode travel t o AV node (decreaseconduction velocity;( + } I n o t r o p y , Chronotropy, Promotropy (_ J Inotropy, Chronotropy, PromotropyP o s i t i v e i n o t r o p yIncrease cardiac contractile force ->Ventricles empty more completelyN e g a t i v e i n o t r o p yWeaken/decrease the force o f myocardialcontractionL e c t u r e3Cardiac Medication, Calcium Channel blockers, Cardiac Arrhythmias, Chest Tube,Congenital -f-fc r tPefects, I n f e c t i o u s Pisease, P P ECalcium Channel b l o c k e r sCCPs (Calcium channel blockers) are tike- Valium for the heart- They relax and slows down the heart- I no t h e r words, CCPs have negative inotropic, chronotropic, dromotropic effects ont h e heartWhen do you want t o relax and slows down the heart?T o treat"A, AA. AAA1'- Antihypertensive- AntiAnginal drugs (decreasin.- AntiA+rialA rrhyt h miaSide Effects-headache and hypotensionName: ends in "dipine"- Ate-D;Verapamil(What are t h e parameters t o assess before putting a p t on CCBs?- Assess for P P- ytald if SPP <1DD- Cardi t e m (diltiatem) i s given continuous I VdripPositive chronotropyIncrease rate o f impulse formation a tSA node -> Accelerate heart rateP o s i t i v e dromotropyIncrease speed that impulses from SAnode travel t o AV node (increaseconduction velocity)Cardiac output improved
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NCLEX Review Notes Mark Klimek Lectures - Page 19 preview imageCdr didc Ar r+hmi d s- Xhowivihow +o ivrterprei- rkitffrhvn.- Wl«s+ know -the follow, 4 cdrdidc- r h +hvns bu sigkri'N o r m a l Sii-iiis Vkut-kiiM- 7 Here isAP wdVe, followed by d QRS, followed be d 7wave for evercomplex- Pedks of +Vie P VedVe i s e Mdll dis+dn+ +o r'/ie Q?S, did fdl! wi tViin 5 swidll boxesExtras:VenPri6«tdr f i b r i l l d Kon- Mo pM+ernVen+r icMtdr “I dr k uc Ar di d- Skidrp pedks wi+h d pdt rerviwyvw.wvvvwMnfiSMsrole
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NCLEX Review Notes Mark Klimek Lectures - Page 20 preview imageThoro df£ "S loyols CTHcirsi'ri knowledge1. Shiftneod +o Ictoy.12 . Shift H'kJ.I-is nice tc blow3- Shift H'ldt i$ wt+s +c blowI ft h e question mentions- QP-.S depolarization - Ventricular- T wave - AtrialT h e C r h y t h m s m o s t t e s t e d on t h e NCLEXT A lack of QBS complexes is asystole—a flat line2 . T waves (atria!) in the form o f saw tooth wave - atrial flutter3 . Chaotic T wave patterns - atrial ftbriNation (a-fi.b) (Chaotic: word used t odescribe fibrillation)4 . Chaotic QBS complexes - ventricular fibrillation (v-fib)6. "bizarre QRS complexes - Ventricular tachycardia (v-tach) ("bizarre: word used t odescribe tachycardia)(p.Teriodic wide bizarre QBS complexes - TVCs (Salvos of TVCs - A short runs o f v-tach)TVCs (premature ventricular contractions) are usually low priority* flow:ever, elevate t h e m t o moderate priority i funder t h e following 3 circumstances- There are(por more TVCs in a minute- More than(pTVCs in a row- V on T phenomenon (a TVC falls on a T wave)* TVCs after an M I is common and is a low priorityLethal arrhythmias are high priority and wnll kill a patient in ft minutes or less. Theyare;« Asystole and V-fib (ventricular fibrillation)♦3oth rhythms produce low or no cardiac output (CO), without which there isinadequate or no brain perfusion. This may lead t o confusion and deathT o t e n t i a l l y L e t h a l Cardiac A r r h y t h m i aV-tach (ventricular tachycardia) is a potentially lethal cardiac rhythm, but it has aCOfjow would a patient with or without CO presents?- CO is absent - there is no pulse- CO i s present - there is a pulse
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NCLEX Review Notes Mark Klimek Lectures - Page 21 preview imageT r e a t m e n t o f ?VCs and V-tach- Ventricular - Lidocaine- t>oth tare ventricular rhythms- Treat with Lidocaine- Amiodarone is eventually the MCLEX hoardwillwant as answerSupraventricular arrhythmias are Atrial arrhythmias (supra - above) T reatvnentsare W C P s "- Adenocard (Adenosine) . . u f a s t I V push [push in less than ft seconds and 2.D vnL MSflush right after)These pts will go into asystole for about ftD seconds and out o fit- Ieta-hlockers (end in -olol)- CCBs- Vigitalis (digoxin), Lanoxin (another digitalis analog)■eta-blockers have negative inotropic, chronotropic,dromotropic effects on t h e heart. They treatr'A, AA, AAA"- Antihypertensive- AntiAnginal drugs (decreasing oxygen demand)- AntiAtrialArythmia- Side Effects - fleadache and hypotensionT r e a t m e n t o f V - f i b and Asystole- Pefil? for V-fih (’Pefih - defihrillate - Shock eml)- Epinephrine and ATopine for AsystoleT)t: A + r i d l drrkiH't'V'ntids- Adfivid- l?€+d- CdkiMrti- PigT x: VOn+r’iCHIrif dt’r’klnHlHiid$- LiJofd.Hd
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NCLEX Review Notes Mark Klimek Lectures - Page 22 preview imageC h e s t T u b e sPurpose: t o reestablish negative pressurein the pleural space ... Negative pressure in■rhe pleural space makes thing stick sothat the lung expands when the chest wallexpands- Pleural space i s t h e space between thelung (visceral pleura j and t h e chest wall(parietal pleura}- T n a pneumothorax, chest t u b e removesair- T n a hemothorax, chest tube removesblood- T n a hemopneumothorax, c h e s t t u b eremoves air and bloodQuestionfi chest tube is placed in a p t for ahemothorax (blood). What would \fou (the L ? N ) report t o t h e nurse? O r , w h a t would40H (thc'RN) report physician?a. Chest t u b e is n o t bubblingb .Chest tube drains ftDO m L in the first I D hoursc. Chest t u b e i s not drainingd.Chest tube is intermittentbubblingWhat is the chest tube not supposed t o do? 1 he chest tube is supposed t o draininstead o f bubblingTherefore answer (c) is the right answer.Questionfi chest tube is placed in a p t for a pneumothorax (air). What would uou (the LPN)report t o the nurse? Dr, what would 40U (the'P.Mj report physician?a. Chest t u b e is n o t bubblingb .Chest tube drains ft 0 0 m L in the first 1.0 hoursc. Chest t u b e i s not drainingd.Chest tube is intermittentbubbling
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NCLEX Review Notes Mark Klimek Lectures - Page 23 preview imageWith a pneumothorax, bubbling is expectedTherefore, (a) is a good answer choice- Since this is a pneumothorax, not -toe much blood is expec ted- Consequently, g»DD m b of blood over AD hours (60 m L per hour) i s toe much bleedand needs -to be reported t o -the nurse er the physicianAlso, pay attention to the location the -tube is placed- Apical (+*p) *>r 'basilar (base)- Apical ches t tube removes Air- "basilar chest tube removes 'blood or fluid (due t o gravity)Examples- An apical chest tube is draining 3DD m b t h e first hour is bad ..."bubbling (air) isexpected- A basilar chest tube i s draining 2 0 0 m L -the first hour is expected- An apical chest tube is not bubbling ....This i s a bad sign because bubbling (air) isexpected- A basilar chest tube is not bubbling ... This is a good sign because bubbling (air) isnot expectedExamplePatient presents w i t h a unilateral hemopneumothorax. flow t o care for -thispatient?Place an apical chest -tube for -the pneumothorax and a basilar for the hemothorax'bilateral pneumothorax needs apical chest -tube one on t h e right and one on -the leftAir tube - Apical - Top, on both sidesP o s t - t r a u m a or p o s t s u r g i c a l p a t i e n t needs- Patient presents with a unilateral hemopneumothorax. -Mow t o care for thispatient? ...place an apical and a basilarchesttube on the side of -the problem ...Always assume trauma and surgery is unilateral unless otherwise specifiedT r i c k guestionWhere would you place a chest tube for a postop r i g h t pneumonectomy?- postop right pneumonectomy does not need a chest -tube ...Since the right lung wasremoved, there is no need for a chest tube
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NCLEX Review Notes Mark Klimek Lectures - Page 24 preview image- Chest tube will however be used for lobectomn (removal o falobe of t h e lang), orwedge resectionClosed c h e s t drainage devicesTpes: Jackson-vratt, Emtsson,pneumovac, hemovac, e tc.What happens i f one of thosedrainage devices i s blocked over?- /Vsk patient t o -take a deepbreath and set the device back up- Motmedical emergency ... Noneed t o ceill -the physician’Knock someone or something over; to push or strike someone or something, causing■the person or -the thing to fall.T ft h e w a t e r seal o f -the c h e s t t u b e b r e a k sClamp- Clamping, unclamping, and placing the tube under water must be done in 1 6 secondsor lessCut t h e tube awauSubmerge (stick) the end of t h e tube under sterile water- The most important stepUnclamp t h e tube if it was initially clamped, (clamping t h e tube preven t a i r t o getinto the chest but does not alloy.' anything from -the chest t o get out)N o t eT f for whatever reason the chest tube breaks, clamp, unclamping -to placing thetube under w a t e r must be done in 1 6 seconds or lessQuestionT h e water sea' chamber of the chest -tube in a patient with apneumo-thorax/hemothorax breaks. What is the first course o f action for the nurse?a. Clamp -the tubeb. Cut t h e tube awac. Submerge (or stick) -the end o f -the tube under sterile waterd. Unclamp the t u b e i f it was initially clamped
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NCLEX Review Notes Mark Klimek Lectures - Page 25 preview image- I nthis case, the first course of action is the clamp the tubeQuestionThe water seal chamber o f the chest tube in a patient with apneumothorax/hemothorax breaks, What is the priority (best) action of t h e nurse?a. Clamp the tubeb. Cut the tube awac. Submerge (or stick) the end of t h e tube under sterile waterd. Unclamp the tube if it was initially clamped- I n this guestion, the priory action for the nurse is t o submerge the end of thetube under sterile water because doing so prevents air from getting into the chest.A t the same time, t h i s allows air or blood from t h e chest to get out(This -solves the problem ky reestablishing t h e water seal)NoteClamping, unclamping, and placing the tube under water- must be done in 15 secondsor lessQuestionVou notice on t h e monitor that a patient has V-fb. p t is unresponsive and there isno pulse. What is t h e first step in t h e management of this patient?a. place a backboard under patient's backwhile patient is supineb. Start chest compression*H?estnis about what is the priori-fry. Chest compressioni s the priority action.I fa c h e s t t u b e g e t s pulled o u t ...1. Take a gloved hand and cover t h e opening (first step)2 . Take a sterile Vaseline gaute and tape 3 sides (best step)Chest tube is bubbling ... Ask (1) where it is bubbling, and ( 2 ) when it is bubbling?Ask the following 2. guestions♦bubbling ... Where?I n the w a t e r seal chamber- I fit i s intermittent, i t is good (document i t )- I fit is continuous, it is bad and indicates a break/leak in the system (find it andtape it)♦bubbling ...Where? I n the suction control chamber
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NCLEX Review Notes Mark Klimek Lectures - Page 26 preview image- I fit is intermittent, suction pressure is too low (increase it a t the wall until it i scontinuous)- I fit i s continuous, i t is good (document it)ftnalogies* ft straight catheter is t o a fotey catheter, as a thoracentesis i s t o a chest tube.- ft straight catheter goes in and out ... ft poley goes in,secure it, and continuousdrainage- Thoracocentesis - go in and o u twChest tubes - g o in, secure it, and [eave it inptace• ft foley has a higher risk o f infection than a straight Cath* ft chest tube has a higher risk o f infection than thoracocentesis"Bules f o r clamping t u b e s- Po not clamp a tube for more than 15 seconds without a physician's order- Use rubber tooth (will not puncture tubing), double clamps- Therefore, when the water seat breaks, the nurse has no more than 15 seconds t oclamp, cut the tube, submerge it under sterile water, and then unclamp itCongenital J-leart pefectsI tis either they cause a lot of trouble or no trouble- E>ut nothing in between♦Memorise one word:,rTRou"HLe" with the lower-case vowels because congenitalheart defects are either:"TBou&Le"o rNothing t o worry aboutft pediatric p a t i e n t w i t h "TRouLe" as congenita! h e a r t defect- Needs surgery now/soon t o live- -Jjas slowed/delayed growth and development (failure t o thrive)- fjas a shortened life expectancy- Parents will experience a tot of grief, financial and emotional stress- Patient is likely t o be discharge home on a cardiac monitor- ftfter, birth, patient will be in the hospital for weeks- Pediatrician or pediatric nurse will likely refer patient t o a pediatric cardiologist
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NCLEX Review Notes Mark Klimek Lectures - Page 27 preview imageQuestion7 h e nurse is teaching the parent o f a n infant l?orvi with “I etralogy o f Eallot. Whichof t h e following should the nurse talked t o t h e parents about in the teachingsession?- T h e nurse should teach the newborn's parents all of the choices listed abovefl "TRotfBLe" congenital heart defect♦"TRouL e " shunts bloodTicjht t o Left♦"TRouS Le" islwe (cyanotic)♦AH "TRouLe" starts with the letter " 7 "- 7 etralocjy o f Eallot- 7runcus arteriosus- 7 ransposition of the- cjreat vessels- 7 ricuspid a t resia- 7 otally anomalous of pulmonary vasculature (7 flTV)- Except, L e f tv e n t r i c u l a r hypoplastic syndrome7 h e s e a r e examples i fMo TRouULe congenital h e a r t d e f e c t s- Ventricular septal defect (VSP)- patent ductus arteriosus (?Pfl)- patent foramen ovale- fltrial septal defect- pulmonic stenosisflII children with a congenital heart defect, whether TRoule defect or No TRou'&ledefect, have- fl Murmur- fln echocardiogram need t o be done t o find out the cause o f the murmur4 d e f e c t s o f T e t r a l o g y o f f a l l o t — "ERDVe"- Pulmonary artery stenosis-TV-H (ricjht ventricular hypertrophy)- Overriding aorta- VSP i Ventricular septal defect)No need t o know w h a t they are ... Just need t o spot them as answer choices on theboard
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NCLEX Review Notes Mark Klimek Lectures - Page 28 preview imageI n f e c t i o n s P i seasc and Transmission-Pased PrecautionsRFtfHXO*-UH. IC o n t a c t precautions• Anything enteric (frl,or fecal/oral)- C. diff, -Hepatitis A. E. coli, cholera, Afsentery• Staph•“RSV (droplets fa!! onto object t h e n patient touches object or put it in mouth)- P o net cohort 2.VSV patievtts unless culture and symptoms saif that have thesame disease•■HerpesTil ere are 4 transmission-based precautions- Standard or universal- Contact- Proplet- Airborne precautionPPE (persona! protective equipment) for contact precaution- Private room is preferred- Can be in t h e same room i f cohort based on culture and not symptoms- -Hand washing -> frown - > frloves- Pisposable SKppfy fgloves, paper pla+es, plas+ie wtensits]- Pedicaied e4uiptnen+ (s+e-bkioseope,l£p ewff) and f o s s+aij in +he roomP r o p1st prec aerbions- for b«gs -travelling on large par+ieles -through Coughing, Sneering -to less than 3fee-t- Meningitis- -H. inflwenia b [Example: epiglottitis (nothing in t h e throat)]PPE (persona! protective E iiipment)- private room is preferred- Can be in the same room if cohort based on culture and symptoms- -Hand washingMask - > froggle or face shield - > frloves- Pisposable supply- Pedica-ted e wipmenta i r b o r n e p r e c a u t i o n s "ftirM T V
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NCLEX Review Notes Mark Klimek Lectures - Page 29 preview image- M WTfc- Varicella (chickenpox)P P £Private room is preferredCan be in the same room i f cohort based on culture and symptoms{Jand washing■> ( oa.a.le or Face shield -> gloves- Wear mask when living the room- Keep door closed- disposable suppKf (not essentialJ- dedicated equipment (not essential)- Negative airflowr D O N N I N GP P € (Personal p r o t e c t i v e e q u i p m e n t )* Order t o put in on:- 6pwn- Mask- fto.e- glovesrD O F F I N G* Order t o take i t off ... d o so in alphabetical order- gloves- Ciole- f own- MaskM a t h Problemsdosage calculationI V drip rates - Volume * drop factor / Time- Micro/Mini drip -(pC‘drops per vnL- Macro drip - W drops per m LPediatric dose (2.2. 1'as - 1 kej)
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NCLEX Review Notes Mark Klimek Lectures - Page 30 preview imageLecture 4Crutches, Canes, Walkers, 'Pefusions, -Hallucinations, Psychosis, Psychotic and Mon -psychotic Hallucination, I l l u s i o n , PelusionC r u t c h e s , Canes, WalkersCruich walking gaH*One of the major human functions is1P012P0*193114s»«locomotion. Therefore, crutches, canesand walkers are tested on the NCLEXexam even though they are n o t reallyemphasised in school, ffso, suchknowledge is good -for patient teaching.With that said, crutches, canes andwalkers are devices used t o help ptsawith an unstable gait, whose mussesare weak or who require a reduction inthe load on weight-bearing structures2f j o w do you measure t h e l e n g t h o fc r u t c h e s ?♦Measuring crutches is important forrisk reduction when ambulating and t oavoid nen/e problems♦T h e length of a crutch i s measured by- Holding it vertically and placing t h e t i pon t h e ground- Having 2 t o 3 finger widths betweent h e pad and t h e a n t e r i o r axillary fold- T h e tip i s located t o a point lateral ( 6inches) and slightly in f r o n t o f footinches)♦"Rule o u t l a n d m a r k s on f o o t o r say axilla!♦fjandgrip measurement- T h e angle of elbow flexion i s 3 0 degrees- T h e wrists should be a t the level o f t h e handgrip
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NCLEX Review Notes Mark Klimek Lectures - Page 31 preview imagef l o w t o Teach Crutch traits?2 -point g a i t —move a crutch and opposite foot together, then the other crutchwith other foo t together* Together (Right leg & Left crutch)“• ogether (Left leg <£."Right crutch)* for mild bilateral leg weaknesses3 -point g a i t —move ( 2 crutches <£.bad leg) -together -> followed by unaffected leg- The gait goes 3-1, 3 -A/ 3-1- The affected (bad) leg is not on the ground- The unaffected (good) leg is on the ground4 -point g a i t—move everything separately- 'Movecrutch -> Move opposite foo-t - > followed by other crutch -> followed byopposite foo-t-"Right crutch -> Left footLeft crutch -> 'Right foot- 4-poin-t gait is Very slow but very stableSwing-th rough is for non- w e i g h t bearing [amputees)- Similar-to 3-point gait- The unaffected foot gets pass the tip of both cru tches- The person may be an ampu tee or does not bear weighton -the leg a tal!- Can move really fast.When do you use t h e s e g a i t s ?♦Use EVen-point g a i t f o r even, odd-point gait f o r odd♦Use the even numbered gaits when weakness in -the feet is evenly distributed- 2-point for mild problems- 4-point for severe♦Use -the odd numbered gait when one leg is affec-ted- 3-point for one leg♦T fpatient cannot bear weight or amputation- Swing-throughExamplepatient affec ted wi th early s tages of rheumatoid arthritis. What gai I- should -thepatient use?- "Hoth legs affected (because it is a systemic disease)
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NCLEX Review Notes Mark Klimek Lectures - Page 32 preview image- Eariij stage—mild- 2 -point gaitExampleA patient has left ATk. (above the knee) amputation 2 da s ago. What gait shouldthe patient use?- Mon-weight bearing- Swing-throughExamplepatient i s first dapostop, right knee, partial weightbearing allowed. What gait should the patient use?- One leg affected- Odd-numbered gait- 3-p*int gaitExample——-*r=Patient is in advanced stages o f ALS. What gait should the patient use?- Trilateral leg weakness (because it is a systemic disease)- Even-numbered gait- Advanced stages - Severe- 4-point gaitExamplePatient with [eft h i p replacement, 2nd daq postop on non-weight bearing instruction.What gait should the patient use?- Non-weight bearing o f 1 leg- Swing-through gaitExamplePatient with bilateral (E / L ) total knee replacement first dat{ postop, weightbearing is allowed. What gait should the patient use?- Even-numbered gait - Trilateral- Weight bearing- firstdafrf postop - Severe- 4-point gait
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NCLEX Review Notes Mark Klimek Lectures - Page 33 preview imageExamplepatient with bila-teraI total knee replacement 3 weeks postop. What gait should thepatient use?- €Ven-numbered gait - Pilateral- Weight bearing- 3 weeks postop - mild- Z-pointftoing U p and Pown -the S t a i r s w i t h Crutches-"Remember this phrase: " u p w i t h -the C ood, and Pown w i t h -the P a d "- When 40a <50 u p -the stairs, the good foot moves u p first- When 40M go down the stairs, the bad foo t moves down lastP u t , . o m a t t e rw h a t : P o t h crutches always move w i t h the bad legCane- -Hold cane on -the anaffected (strong) side- advance cane wi-th the opposite side for a wide base o f support- -handgrip should be a t -the level -the wristWalker• Correc t wai| -to use a walker- The walker is on -the side o f -the p a tient, -the patient "picks it u p ...Se ts it down ...Walks -to i t "- Once -the walker is in front o f -the p a tient, the patient "- olds on t o c h a i r , S tandsu p , T h e n g r a b s w a l k e r "• Pon't tie belongings t o -the front of -the walker — "It h e m t o either side so itwon't tip over• T h e NCLTX board does no t like tennis balls or wheels on walker can create problemPSH h i a t r qF i r s t t h i n g t o a s k in a p s ch guestion i s ; " i st h e p a t i e n t psychotic or non -psychotic?"T h e answer -to this guestion will determine care plan, treatment, length of stavf,legality, etc.
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