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Nclex Study Guide lecture notes Latest 2024
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LECTURE 1l
** DON‟T MIX UP S&S and CAUSATION
- often what causes something is the opposite of the S&S
- ex. diarrhea will cause a metabolic acidosis but once
ACID BASES you are acidotic your bowel shuts down and you get a
paralytic illeus
• learn how to convert lab values to words
• the rule of the B‟s • when you get scenarios:
= if the pH and the BiCarb are both in the same -> if it‟s a lung scenario = respiratory
direction -> metabolic - then check if the client is over-ventilating
Hint: draw arrows beside each to see directions (alkalosis) or under-ventilating (acidosis)
* down = acidosis - remember to look at the words (ex. over, under,
* up = alkalosis ventilating) -> “as the pH goes so goes my PT”
- respiratory -> has no b in it; if in other directions -> VENTILATING DOESN‟T MEAN RESPIRATORY
(or if bicarb is normal value) RATE; resp. rate is irrelevant w/ acid-base,
- KNOW NORMAL pH, BiCarb, CO2 ventilation has to do with gas exchange not resp.
rate (look at the SaO2 -> if your resp. rate is fast
• Hint: DON‟T MEMORIZE LISTS…know principles but SaO2 is low you are under-ventilating)
(they test knowledge of principles by having you -> ex. PCA pump - What acid-base disorder
indicates they need to come off of it? = respiratory
generate lists..) - for “select all” questions
acidosis (resp. depression -> resp. arrest)
- ex. in general/principle what do opioids/pain
—> if it’s not lung, it’s metabolic
meds do? = sedate you, CNS depressors
* ex. what does dilaudid do? don‟t memorize specifics • metabolic alkalosis - really only one scenario = if
or a list of dilaudid, know principles of opioids (such the PT has prolonged gastric vomiting/suctioning
as sedation, CNS depression -> lethargy, flaccidity, - because you are losing ACID
reflex +1, hypo-reflexia, obtunded) * ex. GI surgery w/ NG tube with suctioning for
- boards don‟t test by lists because all books/ 3 days; hyperemesis graviderum
classes have different lists - otherwise everything else that isn‟t lung you
pick metabolic acidosis (DEFAULT)
• principles of S&S acid bases: as the pH goes so * ex. hyperemesis graviderum w/ dehydration
goes my patient (except K+) acute renal failure, infantile diarrhea
- pH up = PT up -> body system gets more
irritable, hyper-excitable (EXCEPT K+) • remember, you only have 4 to pick from:
-> alkalosis - think of a body system and go - respiratory alkalosis - respiratory acidosis
high: hyper-reflexive (+3, +4 [2 is normal]), - metabolic alkalosis - metabolic acidosis
tachypnea, tachycardia, borborygmi, seizure
- pH down = PT down -> body systems shut • pay more attention to the modifying phrases than
down (EXCEPT K+) the original noun
-> acidosis - think of a system and go low: - ex. person w/ OCD who is now psychotic (psychotic
hypo-reflexive (+1, 0), bradycardia, lethargy, trumps OCD); hyperemesis with dehydration (pay
obtunded, paralytic illeus, respiratory arrest attention to dehydration)
• ex. which acid-base disorders need an ambu-bag at
the bedside? = acidosis (resp. arrest) VENTILATION
• ex. which acid-base disorders need suction at the • ventilators -> know alarm systems (you set it up so
bedside? = alkalosis (seize and aspirate) that the machine doesn‟t use less than or more than
• Mac Kussmaul - Kussmaul‟s (compensatory specific amounts of pressure)
respiratory mechanism) is only present in only 1 of a) high pressure alarm = increased resistance
the 4 metabolic (acid-base) disorders to airflow (the machine has to push too hard to
* M = metabolic AC = acidosis get air into lungs)
- from obstructions:
• most common mistake with select all questions = selecting i. kinks in tubing (unkink it)
one more than you should (stop when you select the ones ii. water condensation in tube (empty it!)
you know! don‟t get caught up on the “could be‟s”) iii. mucous secretions in the airway (change
• Hint: don‟t select none or all on select all that apply positions/turn, C&DB, and THEN suction)
questions (never only one and never all)
*** suction is only PRN!!!
-> priority questions = you would check
• Causes of Acid-Base Imbalance:
kinks first, suction is not first
- scenarios and what acid-base disorder would
result (what would cause an imbalance)
, b) low pressure alarm = decreased resistance
to airflow (the machine had to work too little
to push air into lungs)
- from disconnections:
i. main tubing (reconnect it duh!)
ii. O2 sensor tubing (which senses FiO2 at
the airway/trach area; black coated wire
coming from machine right along the
tubing - reconnect!)
• ventilators -> know blood gases
- resp. alkalosis = ventilation settings might be
set too high (OVER-VENTILATING)
- resp. acidosis = ventilation settings might be set
too low (UNDER-VENTILATING)
• ex. weaning a PT off ventilator -> should not be
under-ventilated, they need the ventilator; if they are
over-ventilating then they can be weaned
• never pick an answer where you don‟t do something
and someone else has to do something
,LECTURE 2 - how do you tell the difference between manipulation
& dependency?
ABUSE (Psych and Med-Surge) -> NEUTRAL vs. NEGATIVE (look at what they‟re
Psychological Aspect/Psycho-Dynamics being asked to do)
-> if the sig. other is being asked to do something
• # 1 psychological problem is the same in any/all
abusive situations = DENIAL neutral (no harm) its dependency/co-dependency
- abusers have an infinite capacity for denial so that -> if the sig. other is being asked to do something
they can continue the behavior w/o answering for it that will harm them or is dangerous to them they
• can use the alcoholism rules for any abuse are manipulated
- ex. # 1 psych problem in child abuse, gambling or • how do you treat manipulation?
cocaine abuse is denial - set limits and enforce them -> “NO”
• why is denial the problem? HOW CAN YOU TREAT - easier to treat than dependency/co-dependency
SOMEONE WHO DENIES/DOESN‟T RECOGNIZE because no one likes to be manipulated (no positive
THEY HAVE A PROBLEM self-esteem issue going on)
• denial = refusal to accept the reality of a problem • ex. how many PT‟s do you have w/ denial? = 1
• treat denial by CONFRONTING the problem (it‟s not ex. how many PT‟s do you have w/ dependency/co-
the same as aggression which attacks the person, not dependency = 2
the problem) = they DENY you CONFRONT ex. how many PT‟s do you have w/ manipulation = 1
- pointing out to the person the difference between
what they say and what they do Alcoholism
- Hint: never pick answers that attack the person Wernicke‟s & Korsakoff‟s
-> ex. bad answers have bad pronouns - “you” - typically separate BUT boards lumps them together
-> ex. good answers have good pronouns - “I”, “we” - wernicke‟s = encephalopathy
-> ex. “you wrote the order wrong” vs. “I‟m having - korsakoff‟s = psychosis (lose touch with reality)
difficulty interpreting what you want” -> tend to go together, find them in the same PT
• loss and grief -> for this denial you must SUPPORT it • Wernicke Korsakoff‟s syndrome:
- DABDA = denial, anger, bargaining, depression, acceptance a) psychosis induced by Vit. B1 (Thiamine) deficiency
• Hint: for questions about denial, you must look to see - lose touch w/ reality, go insane because of no B1
if it is LOSS or ABUSE b) primary symptom -> amnesia w/ confabulation
- loss/grief = support - significant memory loss w/ making up stories
- abuse = confront - they believe their stories
• How do you deal w/ these PT‟s?
• #2 psychological problem in abuse = DEPENDENCY, - bad way = confrontation (because they believe what
CO-DEPENDENCY
they are saying and can‟t see reality)
- dependency = when the abuser gets significant other
- good way = redirection (take what the PT can‟t do
to do things for them or make decisions for them
and channel it into something they can do)
-> the dependent = abuser
• Characteristics of Wenicke Korsakoff‟s:
- co-dependency = when the significant other derives
a) it‟s preventable = take Vit. B1 (co-enzyme needed
positive self-esteem from making decisions for or
for the metabolism of alcohol which keeps alcohol
doing things for the abuser
from accumulating and destroying brain cells)
-> the abuser gets a life w/o responsibilities
* PT doesn‟t have to stop drinking
-> the sig. other gets positive self-esteem (which is
b) it‟s arrestable = can stop it from getting worse by
why they can‟t get out of the relationship)
taking Vit. B1
• how do you treat it?
* also not necessary to stop drinking
- set limits and enforce them
c) it‟s irreversible (70% of cases) -> Hint: On boards,
-> start teaching sig. other to say NO (and they
answer w/ the majority (ex. if something is majority
have to keep doing it)
of the time fatal, you say it‟s fatal even if 5% of the
- must also work on the self-esteem of the co-dependent
(ex. I‟m a good person because I‟m saying “no”) time it‟s not)
• manipulation = when the abuser gets the sig. other • Drugs for Alcoholism:
to do things for them that are not in the best interest of DISULFIRAM (Antabuse)
the sig. other = aversion therapy -> want PT‟s to develop a gut
- the nature of the act is dangerous/harmful hatred for alcohol
- how is manipulation like dependency? -> interacts w/ alcohol in the blood to make you very ill
-> in both the abuser is getting the other person to -> works in theory better than in reality
do something for them -> onset & duration: 2 weeks (so if you want to
drink again, wait 2 weeks)
, - PT teaching = avoid ALL forms of alcohol to avoid • Alcohol Withdrawal Syndrome vs. Delirium Tremens
nausea, vomiting & possibly death - they are both different! not the same
-> including mouthwash, aftershaves/colognes/perfumes a) every alcoholic goes through withdrawal 24 hrs.
(topical stuff will make them nauseous), insect after they stop drinking
repellants, any OTC that ends with “-elixer”, alcohol- - only a minority get delirium tremens
based hand sanitizers, uncooked (no-bake) icings - timeframe -> 72 hrs. (alcohol withdrawal comes 1st)
which have vanilla extract, red wine vinaigrette - alcohol withdrawal syndrome ALWAYS precedes
delirium tremens, BUT delirium tremens does not
• Overdoses & Withdrawals: always follow alcohol withdrawal syndrome
- every abused drug is either an UPPER or DOWNER b) AWS is not life-threatening; DT‟s can kill you
-> the other drugs don‟t do anything c) PT‟s w/ AWS are not a danger to self/others; PT‟s
-> #1 abused class of drug that is not an upper or w/ DT‟s are dangerous to self/others
downer = laxatives in the elderly - they are withdrawing from a downer so they will
a) first establish if the drug is an upper or downer be exhibiting upper S&S
- uppers (5) = caffeine, cocaine, PCP/LSD (psychedelic - DT‟s are dangerous
hallucinogens), methamphetamines, adderol (ADD drug) Differences AWS DT
* S&S -> make you go up; euphoria, tachycardia, in Care
restlessness, irritability, diarrhea, borborygmi, Diet Regular diet NPO/clear liquids
hyper-reflexia, spastic, seize (need suction) (because of risk for seizures which
can cause risk of aspiration)
- downers = don‟t memorize names -> anything that
Room Semi-private Private near nurses station
is not an upper is a downer! if you don‟t know what anywhere on (dangerous & unstable)
the med is, you have a high chance that it‟s a the unit
downer if it‟s not part of the uppers list Ambulation Up ad lib Restricted bed rest -> no bathroom
privileges (use bedpans/urinals)
* S&S -> make you go down; lethargy, respiratory
Restraints No restraints Restraints (because dangerous)
depression (& arrest) (because not - not soft wrist or 4 point soft
- ex. The PT is high on cocaine. What is critical to assess? dangerous) because they‟ll get out
-> NOT resps below 12 because they will be high - need to be in vest or 2-pt. locked
leathers (opposite 1 arm & leg,
-> maybe check reflexes rotate Q2hrs, lock the free
b) are they talking about overdose or withdrawal limbs 1st before releasing the
locked ones)
- overdose/intoxication = too much They both get ANTI-HYPERTENSIVES &
- withdrawal = not enough TRANQUILIZERS
- ex. the PT has overdosed on an upper -> pick the - because everything is up (downer withdrawal)
S&S of too much upper They both get MULTIVITAMIN w/ B1
- ex. the PT has overdosed on a downer -> pick the
S&S of too much downer • RN‟s can accept but RPN‟s can‟t (because PT is unstable)
- ex. the PT is withdrawing from an upper -> not - on med-surge, the RN who takes them must decrease
enough upper makes everything go down their workload (i.e. reduce PT load if they take a DT PT)
- ex. the PT is withdrawing from a downer -> not -> Hint: on boards, the setting is always perfect
enough downer makes everything go up (i.e. enough staff/time/resources on the unit etc.)
• upper overdose looks like = downer withdrawal
• downer overdose looks like = upper withdrawal
• In what 2 situations would resp. depression & arrest
be your highest priority:
- downer overdose
- upper withdrawal
• In what 2 situations would seizure be the biggest risk:
- upper overdose
- downer withdrawal
• Drug Abuse in the Newborn:
- always assume intoxication, NOT withdrawal at birth
- after 24 hrs -> withdrawal
- ex. caring for infant of a Quaalude addicted mom 24
hrs. after birth, select all that apply:
-> downer withdrawal so everything is up = exaggerated
startle, seizing, high pitched/shrill cry
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