Mark Klimek NCLEX Review

Mark Klimek NCLEX Review

• Acid Base Principles

Rule of the B’s.. If the​ pH​ & the ​bicarb​ are ​both in the same direction​ = ​Metabolic​ If they are in ​different directions​ = ​Respiratory

●Values: PaO2 → 80-100 mmHg; SaO2 → 95-100%

Example: You are providing care to a client with the following blood gas results: pH 7.32, CO2 49, HCO3 29, PaO2 80 & SaO2 90%. Based on the results, the client is experiencing: ​↓ ​= acidosis, ​↑ ​= respiratory

**NCLEX TIP​:​ Don’t memorize lists, know the principle. Will test the knowledge of a principle by having you generate lists.●Example​: In general, what do opioid pain meds do? They sedate you, CNS depressant. Symptoms you should pick will be options that are down (lethargy, hyporeflexia, obtunded, etc) ●-Opioid: CNS depressant.. know the symptoms (sedation, respiratory depression, etc)..

**Principle: acid base signs/symptoms..

As the pH goes... so goes my patient!!!●When pH goes up; patient goes up.. (everything gets irritable!) ●When pH goes down; patient goes down! (systems in your body shut down) ​… ●Except with potassium​: when pH goes up; potassium goes down... when pH goes down; potassium goes up!

pH UP ↑ K ↓ [ALKALOSIS] pH Down ↓ K ↑ [ACIDOSIS] Tachycardia Tachypnea Diarrhea Tremors Seizure Hyperreflexia (+3/+4) Agitated Borborygmi (↑Bowel Sounds) Hypertension Palpitations Tetany Anxiety/Panic Bradycardia Bradypnea Hypotension ↓ Lucidity Anorexia Coma Lethargy Cardiac arrest Suppressed, decreased, falling Respiratory arrest > ambu bag

1

Kussmaul breathing is a ​deep and labored breathing pattern ​often associated with severe metabolic acidosis, particularly diabetic ketoacidosis (DKA) but also kidney failure... MAC Kussmaul!! ​M: metabolic AC: acidosis Example: Pt has respiratory acidosis... (select all that apply).. ​+1 reflexes​, diarrhea, ​adynamic ileus​, spasm, urinary retention, tachycardia, ​2nd degree mobitz type 2 heart block​, hypokalemia

**NCLEX TIP​:​ ​SATA questions​: *never only 1... never all of them* (New change 2017: can be one answer, some answers, or all of them). ​Main reason that people miss SATA questions is they select one more answer choice then they should. If you don’t know if it applies, don’t pick the answer.

*Causes of acid-base imbalance:

○First ask, “Is it a lung problem?” > YES → Respiratory ○Then, ask yourself, “Are they over ventilating or under ventilating?” i.Over ventilating > over normal > alkalosis (PaCO2 < 35) ii.Under ventilating > under normal > acidosis (PaCO2 > 45) iii.Ventilating doesn’t mean respiratory rate, it deal with gas exchange. Look at SaO2 value.○If it is not a lung problem > Metabolic i.Prolonged gastric vomiting or suctioning > pick ​metabolic alkalosis​ because you are losing acid and becoming more basic ii.Everything else > metabolic acidosis ○If you don’t know an acid-base imbalance based on a condition > pick metabolic acidosis

**NCLEX TIP:​ If you want to get a question right, pay attention to the modifying phrase than the original noun.●A person with obsessive compulsive disorder is now psychotic, you pay more attention to psychotic than the obsessive compulsive disorder.●If prolonged vomiting cause dehydration > you worry more about the dehydration now then the vomiting

Ventilators High pressure alarms are triggered by an increased resistance to air flow (machine is pushing too hard

to get air into the lungs)​. It can be caused by obstructions:

●Kinked Tube ○Nursing action > unkink it ●Water in tubing (caused by condensation) ○Nursing action > empty it/remove H20 ●Mucus in airway ○Nursing action: turn, cough, deep breathe; only use suction if TCDB doesn’t work (last resort) Low pressure alarms are triggered by a decreased resistance to air flow and can be caused by disconnections

of the:

●Tubing ○Nursing action > pay attention to where tubing is…(contamination) ■If tubing is on the floor, change it out ■If tubing is on chest, clean with alcohol then put it back on *Respiratory ​alkalosis ​⇒ OVERVENTILATION ventilator setting may be too ​high​.*Respiratory ​acidosis ​= UNDERVENTILATION = ventilator setting may be too ​low​.What does “wean” mean? gradually decrease with the goal of getting off altogether ●ex: Doc says wean off vent in AM... 6am ABG’s show resp. acidosis... a) follow order b) call respiratory

• hold order.. call doc d) begin to decrease the settings

2

2.) Alcohol Note: Remember in a psych question, if you are asked to prioritize > DO NOT forget Maslow!! Use the

following priorities:

1.Physiological 2.Safety 3.Comfort 4.Psychological 5.Social 6.Spiritual

Also, ALL PSYCH PATIENTS START AS MED SURG PATIENTS...RULE OUT ALL FEASIBLE MED

ANSWERS BEFORE PICKING PSYCH ANSWERS​.

Psychodynamics of Alcoholism ●The ​ ​ #1 problem = DENIAL​*refusal to accept the reality of a problem* ●You treat denial by confronting it

●Treatment:

○Confront it by pointing out to the person the difference between what they say and what they do ○In contrast, support the denial ​loss & grief, don’t confront it ■5 stages of grief​: ​D​enial ​A​nger ​B​argaining ​D​epression ​A​cceptance ○Example: You have a pt that just hand a hand amputated & they say, “I can’t wait to get back to playing the piano”... You say “Oh, how long have you played, etc? - you NEVER say “You can’t because you only have 1 hand” abuse = confront loss = support Dependency/Codependency​ (​#2 problem​) ●Dependency​: when the ​abuser​ gets the significant to do things for them or make decisions for them ●Codependency​: when the ​significant other​ derives ​positive self-esteem​ from doing things for or making decisions ​for the abuser​.

●Treatment:

○Set boundary (limits) and enforce them...Learn to say NO!!○Agree in advance on what requests are allowed than enforce the agreement ○Work on self-esteem of the codependent person

Manipulation ●Definition​: when the abuser gets the significant other to do things for him or her that is ​not in the best interest of the significant other​... the nature of the act is ​dangerous or harmful​ to the significant other.●How is manipulation like dependency? the abuser is getting the other person to do something ○Example: No harm = dependent / co-dependent (wife buying alcohol for husband) dangerous/harmful = manipulated (kid buying alcohol for father) ...depends on legal/illegal.....

●Treatment​:

○Set ​limits​ and ​enforce them ○It's easier to treat than dependency/codependency because ​nobody​ likes to be manipulated

3

Wernicke-Korsakoff Syndrome (WKS)​ ​is a neurological disorder.●Psychosis induced by a ​deficiency in the ​B1 vitamin thiamine​.○Thiamine (B1) plays a role in metabolizing glucose to produce energy for the brain.●Primary symptom of WKS = amnesia with confabulation ○Making up stories to fill in memory los; they believe it is true ○Example: You have a pt who believes he is Ronald Reagan's National Security Officer... And they want to go to a cabinet meeting.../ WHAT DO YOU DO?!? ​Redirect!!​ (“well, why don’t you get a shower and then we’ll go watch CNN and see what the news is in Washington

D.C.”)

●Characteristics:

○Preventable ■Give B1 vitamins ○Arrestable ■Can stop it from getting worse - not imply better ○Irreversible ■Dementia symptoms don’t get better - only worse

**NCLEX Tip: ​Always answer with the majority

Antabuse (disulfiram)/Revia​ ​-alcoholism medication *​aversion therapy!​* ●It can treat problem drinking by creating an unpleasant reaction to alcohol. It's used in recovery programs that include medical supervision and counseling.●Onset and duration of effectiveness > ​2 weeks ○Take drug for 2 weeks and builds up in the blood level that when drinking alcohol, they will become horribly sick ○If they stop taking the drug for 2 weeks, they will be able to drink alcohol without getting sick ●Patient teaching - Avoid ALL forms of alcohol to avoid ​nausea​, ​vomiting​ and ​possibly death ○NO​: mouthwash, aftershaves, perfumes/colognes, insect repellants, any OTC elixirs (ex: Robitussin), alcohol-based hand sanitizers, un-cooked icings (vanilla extract)...○However, they CAN have RED WINE VINAIGRETTE!

*Overdoses/Withdrawals.​..First ask yourself, “Is the drug an ​upper​ or a ​downer​?” ●Exception > Laxative (not upper or downer) but can be abused by the elderly..

Uppers ↑ Downers ↓

Names:

●Caffeine ●Cocaine ●PCP/LSD (Psychedelic hallucinogens) ●Methamphetamines - speed ●ADHD - adderall/Ritalin ●Bath Salts (Cath-Rath) Names ●Everything else that is not an upper

Signs/Symptoms:

Tachycardia Hypertension Diarrhea Agitation Tremors Clonus Belligerence ​ Seizures Exaggerated, shrill, high pitched cry Difficult to console Borborygmi Euphoria Hyperreflexia **Need suction

Signs/Symptoms:

Bradycardia Hypotension Constipation Constricted pupils Flaccidity ​ Respiratory arrest Decreased core body temp Lethargy Hyporeflexia

**Need Ambu bag 4