NCLEX Review Notes

Acid-Base Balance

  • Normal values: pH (7.35-7.45), CO2, HCO3 (bicarbonate).

  • pH < 7.35: Acidosis; pH > 7.45: Alkalosis.

  • Rule of the Bs: pH and Bicarb move in same direction = Metabolic. Opposite = Respiratory.

  • Low pH: everything low (except potassium). High pH: everything high (except potassium).

  • Metabolic Acidosis with Kussmaul respirations: “MAC Kussmaul”.

  • Lung? Yes = respiratory. Overventilating = alkalosis. Underventilating = acidosis.

  • Not lung? Metabolic. Prolonged vomiting/suction = alkalosis. Otherwise = metabolic acidosis.

Ventilators

  • High-pressure alarm: increased resistance. Check for kinks, water, mucus plugs.

  • Low-pressure alarm: decreased resistance. Check for disconnection. Bag patient, call RT.

  • High setting: respiratory alkalosis. Low setting: respiratory acidosis.

  • Respiratory acidosis: patient not ready to wean.

Alcoholism

  • #1 Psychological Problem: Denial. Confront abuse, support loss.

  • Dependency/Co-dependency: Abuser (dependent) gets free ride on the do-er (co-dependent).

    • Confront dependent, teach co-dependent to set limits.

  • Manipulation: Abuser gets the other to do harmful things. Set limits and enforce.

Wernicke-Korsakoff Syndrome

  • Psychosis from Vitamin B1 (thiamine) deficiency.

  • Amnesia and confabulation.

    • Redirect patient. Preventable, arrestable, irreversible (70%).

Antabuse/Revia

  • Alcohol deterrent. Aversion therapy.

  • Onset/duration: 2 weeks. Patient teaching: avoid all EtOH forms.

Overdose/Withdrawal

  • Upper or Downer? Upper: Anticipate suction. Downer: Anticipate ventilation.

    • Overdose: Too much. Withdrawal: Too little.

  • Newborn < 24 hours: intoxication. > 24 hours: withdrawal.

Alcohol Withdrawal vs. Delirium Tremens

  • AWS: ~24 hrs after stopping. DT: ~72 hrs. AWS precedes DT, but not always.

  • Respiratory arrest risk: Downer OD, Upper withdrawal. Seizure risk: Upper OD, Downer withdrawal.

Aminoglycosides

  • "A Mean Old Mycin." Treat serious, resistant Gram- infections.

  • Toxic effects: Ototoxicity (hearing, balance, tinnitus), nephrotoxicity (creatinine).

  • Admin q8 hours. Give IM/IV, not PO, except hepatic encephalopathy and pre-op bowel surgery.

    • Action of oral mycin: sterilize the bowel. (“Neo Kan”).

Troughs and Peaks

  • Trough: 30 min before dose. Peak: SubL (5-10 min after dissolved), IV (15-30 min after finished), IM (30-60 min).

Calcium Channel Blockers

  • Like Valium for the heart. Negative inotropic, chronotropic, dromotropic.

  • Treat “A, AA, AAA”: Antihypertensive, AntiAnginal, AntiAtrialArrhythmia.

  • Side Effects: Headache and hypotension. Ends in "dipine", verapamil, Cardizem (diltiazem).

  • Hold if SBP < 100.

Cardiac Arrhythmias

  • QRS depolarization: Ventricular. P wave: Atrial.

    • Asystole: flat line. Atrial flutter: saw tooth P waves. A-fib: chaotic P waves, V-fib: chaotic QRS complexes, V-tach: bizarre QRS complexes, PVCs: periodic wide bizarre QRS complexes.

  • Lethal: Asystole, V-fib. Potentially Lethal: V-tach (has CO).

  • Ventricular (Lidocaine, Amiodarone). Supraventricular (Adenocard, Beta-blockers, CCBs, Digitalis).

  • V-fib: Defib. Asystole: Epinephrine, Atropine.

Chest Tubes

  • Reestablish negative pressure. Pneumothorax: removes air. Hemothorax: removes blood.

  • Apical: removes air. Basilar: removes blood.

  • Water seal breaks: clamp, cut away, submerge in sterile water, unclamp.

  • Tube pulled out: cover opening, sterile Vaseline gauze and tape 3 sides.

  • Water seal bubbling: intermittent good, continuous bad. Suction control bubbling: intermittent low, continuous good.

Congenital Heart Defects

  • TRouBLe: Needs surgery, slowed growth, shortened life, Right to Left shunt, Blue (cyanotic). Starts with "T".

  • No TRouBLe: VSD, PDA, PFO, ASD, Pulmonic stenosis.

  • All have murmur and need echocardiogram.

  • Tetralogy of Fallot: “PROVe” (Pulmonary stenosis, RVH, Overriding aorta, VSD).

Infectious Disease and Transmission-Based Precautions

  • Contact: enteric, Staph, RSV - Hand washing, gown, gloves, disposable supplies, dedicated equipment.

  • Droplet: large particles < 3 feet, Meningitis, H. influenza - Hand washing, mask, goggle, gloves, disposable supplies, dedicated equipment.

  • Airborne: Air MTV (MMR, TB, Varicella) - Hand washing, N95, goggle, gloves, negative airflow, closed door.

Crutches

  • Measure: 2-3 finger widths below axilla, tip lateral/in front of foot. Handgrip: 30-degree elbow flexion.

  • Gaits: 2-point (mild bilateral), 3-point (one leg affected), 4-point (severe bilateral), swing-through (non-weight bearing).

  • “Up with the Good, and Down with the Bad” (stairs). Canes: hold on strong side, advance with opposite.

  • Walkers: “Pick it up, Set it down, Walk to it”. Don’t tie items to front.

Psychiatry

  • Psychotic: no insight, not reality based. Non-psychotic: insight, reality-based.

    • Therapeutic communication for non-psychotic patients.

  • Delusions: fixed false belief. Hallucination: sensory experience. Illusion: misinterpretation of reality.

  • Functional psychosis: acknowledge feeling, present reality, set limits, enforce.

  • Psychosis of dementia: acknowledge feeling, redirect.

  • Psychotic Delirium: acknowledge feeling, reassure safety and temporariness.

  • Loose associations: flight of ideas, word salad, neologisms.

Diabetes Mellitus, Insipidus, SIADH

  • DM: error in glucose metabolism. DI: polyuria, polydipsia (low ADH). SIADH: oliguria, no thirst.

  • Type 1: Insulin dependent, ketosis prone. Type 2: Non-insulin dependent, non-ketosis prone.

  • Type 1 Treatment: Diet, Insulin, Exercise. Type 2: Diet, Oral hypoglycemic, Activity.

  • Diet DM2: calorie restriction, 6 small feedings.

Insulin

  • R (Regular): Clear, rapid, IV drip. Onset: 1 hour. Peak: 2 hours. Duration: 4 hours.

  • N (NPH): Cloudy, Intermediate. Onset: 6 hours. Peak: 8-10 hours. Duration: 12 hours.

  • Lispro: Give with meal. Onset: 15 min. Peak: 30 min. Duration: 3 hrs.

  • Glargine: Long-acting, no peak, lasts 12-24 hrs. Little to no hypoglycemia risk.

  • Once opened insulin expires in 30 days.

  • Exercise potentiates insulin. Sick days: need insulin, sips of water.

  • Low blood glucose: drunk in shock. Treat with rapidly metabolizable carbs.

  • DKA: Type 1, high glucose, ketones, dehydration, Kussmauls. Treat with insulin and IV fluids.

  • HHNK: Type 2, dehydration. Treat by rehydration. Higher mortality than DKA.

  • Long-term complications: Poor perfusion, peripheral neuropathy. HbA1c: glucose level over 90 days.

Drug Toxicities

  • Lithium (0.6-1.2), Lanoxin (1-2), Aminophylline (10-20), Dilantin (10-20), Bilirubin (0.2-1.2 adults, 10-20 newborns).

  • Kernicterus: bilirubin in brain (>20). Opisthotonos: hyperextended posture. Place child on their side.

Dumping Syndrome vs. Hiatal Hernia

  • Hiatal Hernia: regurgitation upward. GERD symptoms lying down after meal. Elevate HOB, increase fluids/carb content.

  • Dumping Syndrome: dumps too quickly. Drunk, shock, acute abdominal distress. Lower HOB, decrease fluids/carb content, increase protein.

Electrolytes

  • Kalemias: do the same as the prefix, except HR and UO go opposite. Calcemias/Magnesemias: do the opposite.

  • HypoNatremia = Volume overload, HyperNatremia = Dehydration.

  • Early signs of electrolyte imbalance: numbness and tingling, muscle weakness.

  • Never Push Potassium IV. Give D5W and regular insulin to lower potassium quickly.

  • Kayexalate: exchanges K for Na (long term).

Thyroid and Adrenals

  • Hyperthyroidism: hypermetabolism. Weight loss, HR/BP up, heat intolerance, exophthalmos (Graves disease).

    • Treatments: radioactive iodine, PTU, thyroidectomy.

  • Hypothyroidism: hypometabolism. Cold intolerance. Treat with levothyroxine (Synthroid) in morning.

  • Addison’s: hypoadrenalism. Hyperpigmented, don’t adapt to stress. Treat with steroids (-SONE).

  • Cushing’s: oversecretion of steroids. Moon face, truncal obesity, high glucose. Treat with adrenalectomy.

Kids Toys

  • Safe, age-appropriate, feasible. No small toys for kids <4. No metal with oxygen. Fomites problematic.

  • Infants (0-6m): musical mobile. (6-9m): cover/uncover, firm. (9-12m): verbal toys.

  • Toddlers (1-3y): gross motor, push/pull toys. Preschoolers (3-6y): fine motor, balance, cooperative play.

  • School age (7-11y): concrete, creative, collective, competitive. Adolescents (12-18y): peer group.

Laminectomy

  • Removes nerve root compression (Pain, Paresthesia, Paresis).

  • Cervical: assess breathing and arm function. Thoracic: assess cough and bowel function.. Lumbar: assess urinary retention and leg function.

  • Post-op: log roll. Don’t dangle. Don’t sit >30 min. Lift by bending at knees, not waist.

  • Cervical: don’t lift over head. No riding, biking, jerky rides.

Lab Values

  • Prioritize with “ABCD” scheme. Deadly “Ds”: K+>6, pH in the 6s, CO2 in the 60s, pO2 <60, Platelets <40,000

Psychiatric Drugs

  • ALL cause low BP and weight changes.

  • Phenothiazines: end in "ZINE". Antipsychotics: ABCDEFG side effects.

  • Tricyclic Antidepressants: Elevates mood. ABCD side effects. Take 2 to 4 weeks for benefits.

  • Benzodiazepines: anti-anxiety, end in "Pam" or "Lam”. ABCD side effects. Use short term.

  • MAO Inhibitors: MAR, NAR, PAR. Avoid tyramine. Hypertensive crisis.

  • Lithium: for bipolar. 3Ps side effects. Monitor sodium.

  • Prozac: SSRI. ABCD side effects. Give before noon.

  • Haldol: tranquilizer. NMS vs EPS (check temp).

  • ClozariL: Atypical antipsychotic. aGranulocytosis

  • Zoloft: Serotonin syndrome (SAD Head).

Maternity and Neonatology

  • Naegele’s rule (LMP + 7 days - 3 months). Weight gain during pregnancy. Fundal heigh at 12-12 weeks. Positive signs of pregnancy. Fetal HR (8-12 weeks), Quickening (16-20 weeks).

  • Maybe signs of pregnancy: Positive hCG, Chadwick, Goodell, Hegar sign.

  • Prenatal visits: monthly to 28 wks, every other week 28-36, weekly after 36 to delivery.

  • Hb levels fall during pregnancy and can fall to 11 then 10.5 then 10 based on trimester.

  • Tx for morning sickness, UI, difficulty breathing, back pain.

  • Onset of regular/progressive contractions is VALID true sign of labor. Cervical dilation (0-10cm), effacement, station.

  • Lie is relationship between mother and fetus spines.

Stages of Labor

  • Stage 1: onset to full dilation; Latent (0-4cm), Active (5-7), Transition (8-10cm).

  • Stage 2: delivery of baby. Stage 3: delivery of placenta. Stage 4: recovery (2 hours).

  • Assess the placenta for smoothness, intactness, and umbilical cord present.

  • Remember contraction should be no longer than 90 seconds and no closer than 2 minutes.

  • Complications of labor: Painful back pain, prolapsed cord… Remember position and push.

Complications and Meds

  • Painful Back pain - “OP” and apply position and push, otherwise