Mark Klimek NCLEX Review
Acid Base Balance
Rule 1: If the pH & the HCO3 are in the
same direction METABOLIC if they are
Alkalosis – as the pH goes UP the pt body gets IRRITATED except for K+
opposite direction RESPIRATORY
Rule 2: pH determines Acidosis or Alkalosis Acidosis – as the pH goes DOWN the pt body SHUTS DOWN except for K+
pH 7.35 – 7.45
HCO3 22 -- 26
CO2 45 – 35
1. IS IT LUNGS? yes = RESPIRATORY (remember, not just breathing, look for gas exchange spaO2)
2. Over ventilating = Alkalosis
Under ventilating = Acidosis
1. IT’S NOT LUNGS? = METABOLIC (gastric)
2. Is it prolonged suctioning or vomiting? Yes = Alkalosis (borygmi)
3. Everything else = Acidosis (dehydration, burns, renal, diarrhea, etc)
Ventilators
↑pressure alarm: 1st kink 2nd condensation 3rd mucus fix kink, empty tube, reposition, suction – in that order
↓pressure alarm: there is a disconnection or a leak
Alcoholism/ALL Abuse
#1 ABUSERS PROBLEM IS DENIAL CONFRONT PROBLEM WO ATTACKING– STATE WHAT YOU SEE avoid “you answers”
#2 ABUSERS PROBLEM IS DEPENDENCY SET LIMITS & LEARN TO SAY NO! – WORK ON CODEPENDENT’S SELF ESTEEM
#3 ABUSERS PROBLEM IS MANIPULATION HARMFUL/DANGEROUS TO THE DEPENDENT
Wernike’s/Korsacoff Alcoholism
W = encephalopathy K = psychosis
- Preventable & Irreversible amnesia and confabulation (they believe what they are saying is true)
- LEARN TO REDIRECT NOT REORIENT
- TAKE B1 VITAMIN
- Antabuse/Disulfiram – eversion therapy (makes them hate ETOH & makes them sick if they drink it)
Avoid ETOH of all kinds . . . mouthwash, aftershave, perfume, insect repellent, OTC that ends in
elixir, hand sanitizer, unbaked vanilla icing, vinaigrette
OVERDOSE/WITHDRAWAL
UPPERS PCP/LSD, caffeine, cocaine, methamphetamines, Adderall
OD = seizure
WD = respiratory depression s/s *** ALWAYS ASSUME BABY IS
DOWNERS everything else INTOXICATED AND NOT
OD = respiratory depression s/s WITHDRAWING at birth or in first 24
WD = seizure hours. AFTER 24 HOURS, BABY IS
Delirium Tremens WITHDRAWING
“DT’s” 72 hours after last drink…. Not everyone goes through this & can kill you.
o not stable, danger to self and others
o Private, near nurse’s station
o NPO or Clear liquid
o Restricted Bedrest- no getting up to go to the bathroom -- urinal and bedpan
o Restrained, vest or leather restraints, two point leather restraints.
, o Antihypertensive, B1 vitamin
o Tranquilizer b/c withdrawal stage –major
ALCOHOL WITHDRAWAL SYNDROME:
W/IN 24HR OF LAST DRINK.
- Up at lib
- Regular Diet
- Semiprivate room
- No restraints
- Antihypertensive
- B1 vitamin
- Tranquilizer b/c of withdrawal stage – minor
Aminoglycosides
powerful – last resort antibiotics “A mean old mycin”
Hard to treat infections: mRSA, TB, Septic, cancer, resistant infections
MEAN OLD MYCIN END IN MYCIN; IF THEY
NOT AMINOGLYCOCIDES: EryTHROmycin, AziTHROmycin, ClariTHROmycin
HAVE THRO, THROW THEM OFF THE LISTS.
Ototoxicity
- Monitor hearing, Balance, Equilibrium, Tinnitus
- HOLD DRUG AND CALL DOCTOR
Nephrotoxicity
- monitor CREATINE BEST INDICATOR OF KIDNEY FUNCTION!
- Fluid balance is measured best by daily weight.
o TOXIC TO CRANIAL NERVE NUMBER 8
o GIVE EVERY 8 HOURS IM AND IV only
o DO NOT GIVE PO BC NOT ABSORBED.
o NEOMYCIN/CANAMYCIN ORALLY FOR STERILE BOWEL. – hepatic coma, PREP bowel surgery, C. Diff
Peak & Trough on Toxic drugs
Peak and Trough are drawn on TOXIC DRUGS because of narrow therapeutic
range.
RN is hanging 100 ml of an IV antibiotic.
With peak and trough the drug itself is irrelevant! You have to know the route.
Its running at 200 an hour. Hung at 10.
What time will remind the RN that the
Sublingual/IV/IM/SubQ/PO Trough- 30 minutes before the next dose Peak needs drawn. Answer: 10:45-
Sublingual Peak- 5-10 min after drug is DISOLVED 11:00. If you get two right answers in
IV Peak- 15-30 minutes after drug is finished & BAG IS EMPTY the range pick the highest number
IM Peak- 30-60 min without going over like the price is right
Calcium Channel Blockers
It’s Valium for your heart -- calms you down & decreases your heart rate. -Dipine-CCB
Low BP or arrythmia: no you don’t give CCB – BP systolic <100 HOLD THE DRUG -cardiZem-CCB – only IV drip
CCB have negative inotropic effects on the heart -- means like valium for the heart! -Verapimil-CCB
Side Effects headache and Hypotension
, Treatment:
A-Antihypertensive-- relaxes heart & blood vessels – in result it decreases the BP
AA- Anti-angina—relaxes the heart & decreases O2 demand
AAA- Anti-Atrial-Arrhythmic- treats Afib, PAC, ATACH, Aflutter. SVT!!!!
Arrhythmias
QRS question always VENTRICULAR Chaos = fibrillation
P wave question always ATRIAL
o lack of QRS- Asystole – Bizarre = tachycardia
shockable
o Saw tooth- Aflutter
TREATMENT OF ARRHYTHMIAS
o Chaotic P – A fib
o Chaotic QRS- V fib -- shockable PVC and VTACH
o Continuous Bizarre, QRS - VTACH - Lidocaine, amiodorone
o Episodic Bizarre QRS- PVC
Atrials
PVC can become moderate priority if these 3 things occur: A- adenocard (adenosine slam it in
o > 6 in a minute in less than 8 seconds)
o > 6 in a row B- betablockers all end in –lol
o falls on T wave (R on T) C- CCB
o Have to have a 60 systolic pressure to get a carotid D- Digitalis, Digoxin, Lanoxin
o Have to have a 70 systolic pressure to get femoral
o Have to have an 80 systolic pressure to get a radial FOR VFIB YOU DEFIB
Asystole
Chest tubes
- Epinephrine and Atropine
Reestablishes negative pressure in the pleural space
Air and blood enter pleural space creating positive pressure = bad.
Chest tube placed for a . . . . . .
Pneumothorax is for removing air so it should bubble APICAL CHEST TUBE PLACED – THREADED TO APEX
▪ No drainage = GOOD
▪ 800ml/hour = BAD
Hemothorax you should see blood and NO bubble BASILAR CHEST TUBE PLACED – AT BASE D/T GRAVITY
▪ No drainage = BAD
▪ 800ml/hour = GOOD
Pneumohemothorax bubble and blood
Do not clamp chest tubes for
Troubleshooting chest tubes:
longer than 15 seconds unless
1. If you knock it over?
doctors order says. When you
o sit it up and have them take some deep breaths.
do clamp do double clip rubber
2. What if you break it/ crack water seal? In order tip clamps.
o clamp tube so nothing can get in. **Do 1st if priority question
o Cut tube away from broken device.
o Submerge end of tube under water. ** BEST choice b/c it solves the problem
o THEN unclamp it.
3. If chest tube gets pulled out?
Acid Base Balance
Rule 1: If the pH & the HCO3 are in the
same direction METABOLIC if they are
Alkalosis – as the pH goes UP the pt body gets IRRITATED except for K+
opposite direction RESPIRATORY
Rule 2: pH determines Acidosis or Alkalosis Acidosis – as the pH goes DOWN the pt body SHUTS DOWN except for K+
pH 7.35 – 7.45
HCO3 22 -- 26
CO2 45 – 35
1. IS IT LUNGS? yes = RESPIRATORY (remember, not just breathing, look for gas exchange spaO2)
2. Over ventilating = Alkalosis
Under ventilating = Acidosis
1. IT’S NOT LUNGS? = METABOLIC (gastric)
2. Is it prolonged suctioning or vomiting? Yes = Alkalosis (borygmi)
3. Everything else = Acidosis (dehydration, burns, renal, diarrhea, etc)
Ventilators
↑pressure alarm: 1st kink 2nd condensation 3rd mucus fix kink, empty tube, reposition, suction – in that order
↓pressure alarm: there is a disconnection or a leak
Alcoholism/ALL Abuse
#1 ABUSERS PROBLEM IS DENIAL CONFRONT PROBLEM WO ATTACKING– STATE WHAT YOU SEE avoid “you answers”
#2 ABUSERS PROBLEM IS DEPENDENCY SET LIMITS & LEARN TO SAY NO! – WORK ON CODEPENDENT’S SELF ESTEEM
#3 ABUSERS PROBLEM IS MANIPULATION HARMFUL/DANGEROUS TO THE DEPENDENT
Wernike’s/Korsacoff Alcoholism
W = encephalopathy K = psychosis
- Preventable & Irreversible amnesia and confabulation (they believe what they are saying is true)
- LEARN TO REDIRECT NOT REORIENT
- TAKE B1 VITAMIN
- Antabuse/Disulfiram – eversion therapy (makes them hate ETOH & makes them sick if they drink it)
Avoid ETOH of all kinds . . . mouthwash, aftershave, perfume, insect repellent, OTC that ends in
elixir, hand sanitizer, unbaked vanilla icing, vinaigrette
OVERDOSE/WITHDRAWAL
UPPERS PCP/LSD, caffeine, cocaine, methamphetamines, Adderall
OD = seizure
WD = respiratory depression s/s *** ALWAYS ASSUME BABY IS
DOWNERS everything else INTOXICATED AND NOT
OD = respiratory depression s/s WITHDRAWING at birth or in first 24
WD = seizure hours. AFTER 24 HOURS, BABY IS
Delirium Tremens WITHDRAWING
“DT’s” 72 hours after last drink…. Not everyone goes through this & can kill you.
o not stable, danger to self and others
o Private, near nurse’s station
o NPO or Clear liquid
o Restricted Bedrest- no getting up to go to the bathroom -- urinal and bedpan
o Restrained, vest or leather restraints, two point leather restraints.
, o Antihypertensive, B1 vitamin
o Tranquilizer b/c withdrawal stage –major
ALCOHOL WITHDRAWAL SYNDROME:
W/IN 24HR OF LAST DRINK.
- Up at lib
- Regular Diet
- Semiprivate room
- No restraints
- Antihypertensive
- B1 vitamin
- Tranquilizer b/c of withdrawal stage – minor
Aminoglycosides
powerful – last resort antibiotics “A mean old mycin”
Hard to treat infections: mRSA, TB, Septic, cancer, resistant infections
MEAN OLD MYCIN END IN MYCIN; IF THEY
NOT AMINOGLYCOCIDES: EryTHROmycin, AziTHROmycin, ClariTHROmycin
HAVE THRO, THROW THEM OFF THE LISTS.
Ototoxicity
- Monitor hearing, Balance, Equilibrium, Tinnitus
- HOLD DRUG AND CALL DOCTOR
Nephrotoxicity
- monitor CREATINE BEST INDICATOR OF KIDNEY FUNCTION!
- Fluid balance is measured best by daily weight.
o TOXIC TO CRANIAL NERVE NUMBER 8
o GIVE EVERY 8 HOURS IM AND IV only
o DO NOT GIVE PO BC NOT ABSORBED.
o NEOMYCIN/CANAMYCIN ORALLY FOR STERILE BOWEL. – hepatic coma, PREP bowel surgery, C. Diff
Peak & Trough on Toxic drugs
Peak and Trough are drawn on TOXIC DRUGS because of narrow therapeutic
range.
RN is hanging 100 ml of an IV antibiotic.
With peak and trough the drug itself is irrelevant! You have to know the route.
Its running at 200 an hour. Hung at 10.
What time will remind the RN that the
Sublingual/IV/IM/SubQ/PO Trough- 30 minutes before the next dose Peak needs drawn. Answer: 10:45-
Sublingual Peak- 5-10 min after drug is DISOLVED 11:00. If you get two right answers in
IV Peak- 15-30 minutes after drug is finished & BAG IS EMPTY the range pick the highest number
IM Peak- 30-60 min without going over like the price is right
Calcium Channel Blockers
It’s Valium for your heart -- calms you down & decreases your heart rate. -Dipine-CCB
Low BP or arrythmia: no you don’t give CCB – BP systolic <100 HOLD THE DRUG -cardiZem-CCB – only IV drip
CCB have negative inotropic effects on the heart -- means like valium for the heart! -Verapimil-CCB
Side Effects headache and Hypotension
, Treatment:
A-Antihypertensive-- relaxes heart & blood vessels – in result it decreases the BP
AA- Anti-angina—relaxes the heart & decreases O2 demand
AAA- Anti-Atrial-Arrhythmic- treats Afib, PAC, ATACH, Aflutter. SVT!!!!
Arrhythmias
QRS question always VENTRICULAR Chaos = fibrillation
P wave question always ATRIAL
o lack of QRS- Asystole – Bizarre = tachycardia
shockable
o Saw tooth- Aflutter
TREATMENT OF ARRHYTHMIAS
o Chaotic P – A fib
o Chaotic QRS- V fib -- shockable PVC and VTACH
o Continuous Bizarre, QRS - VTACH - Lidocaine, amiodorone
o Episodic Bizarre QRS- PVC
Atrials
PVC can become moderate priority if these 3 things occur: A- adenocard (adenosine slam it in
o > 6 in a minute in less than 8 seconds)
o > 6 in a row B- betablockers all end in –lol
o falls on T wave (R on T) C- CCB
o Have to have a 60 systolic pressure to get a carotid D- Digitalis, Digoxin, Lanoxin
o Have to have a 70 systolic pressure to get femoral
o Have to have an 80 systolic pressure to get a radial FOR VFIB YOU DEFIB
Asystole
Chest tubes
- Epinephrine and Atropine
Reestablishes negative pressure in the pleural space
Air and blood enter pleural space creating positive pressure = bad.
Chest tube placed for a . . . . . .
Pneumothorax is for removing air so it should bubble APICAL CHEST TUBE PLACED – THREADED TO APEX
▪ No drainage = GOOD
▪ 800ml/hour = BAD
Hemothorax you should see blood and NO bubble BASILAR CHEST TUBE PLACED – AT BASE D/T GRAVITY
▪ No drainage = BAD
▪ 800ml/hour = GOOD
Pneumohemothorax bubble and blood
Do not clamp chest tubes for
Troubleshooting chest tubes:
longer than 15 seconds unless
1. If you knock it over?
doctors order says. When you
o sit it up and have them take some deep breaths.
do clamp do double clip rubber
2. What if you break it/ crack water seal? In order tip clamps.
o clamp tube so nothing can get in. **Do 1st if priority question
o Cut tube away from broken device.
o Submerge end of tube under water. ** BEST choice b/c it solves the problem
o THEN unclamp it.
3. If chest tube gets pulled out?
