Summer casablancas

Diner vibes

Examples:  lisinopril, enalapril, and captopril 

Action:  decreases peripheral vascular resistance to decrease blood pressure; indicated for heart failure and hypertension 

Side effects:  postural hypotension, dizziness, nonproductive cough, angioedema, kidney injury, and hyperkalemia

Nursing considerations:  (1) assess patient for history of renal impairment, as ACE inhibitors may exacerbate kidney injury; (2) teach patient to seek immediate medical attention if he/she experiences swelling of the lips (angioedema; as pictured), as severe angioedema may cause respiratory distress; (3) teach patient to notify HCP if a nagging cough develops

Also of note:  ACE inhibitors are contraindicated during second- and third-trimester pregnancies

My clinical experience:  

(1) Angioedema with ACE inhibitor use is quite common, especially with African Americans and may not manifest itself for months/years after starting an ACE inhibitor. 

(2) In light of acute kidney injury, doctors do often suspect fault with ACE Inhibitors and will hold/discontinue medications as appropriate. 

(3) A patient with a nonproductive cough, another common complication, although certainly not an immediate concern, will likely be switched to another class of medication. 

It is common to see “normal lab values” that differ slightly from what you see in your textbook or at the hospital. Laboratory reference values often vary among reference sources and are highly dependent on the analytic methods used.

The NCLEX will not ask you to identify lab values with only slight variations from the norm because of this widely-known fact! Instead, questions on lab values will be obviously “off” or else you will be told about an abnormal lab result and then tested on your understanding of the implications of that result: can you anticipate the manifestations, the risks associated with it, or how to intervene?

Don’t focus on memorizing every reference range, but do learn the ones that are likely to show up on the NCLEX.  The following labs are specifically listed on the detailed version of the NCLEX Test Blueprint:

• pH: 7.35 - 7.45

• PO2: 80 - 100

• SaO2: 95 - 100%

• HCO3: 21 - 28 mEq/L or 21 - 28 mmol/L

• BUN: 10-20 mg/dL or 3.6-7.1 mmol/L

• Creatinine 0.5-1.2  mg/dL or 44-106 µmol/L.

• Cholesterol (total): <200 mg/dL or <5.0 mmol/L

• Glucose: 70 - 110 mg/dL (fasting) and  ≥ 200 (casual) or  <6.1 mmol/L (fasting) or ≥ 11.1 mmol/L (casual).

• Critical glucose levels are <40 and >400 mg/dL or <2.22 and >22.2 mmol/L .

• Hematocrit: 37-52% or 0.37-0.52 volume fraction

• Hemoglobin: 12-18 g/dL or 120-180 mmol/L

• HbA1C: 4-5.9% (nondiabetic), < 7% (good diabetic control), > 9% (poor diabetic control)

• Platelets: 150,000-400,000/mm³ or 150-400 x10⁹/L.

• Potassium: 3.5-5.0 mEq/L or 3.5-5 mmol/L.

• Sodium: 136-145 mEq/L or 136/145 mmol/L.

• WBC: 5,000-10,000/mm³ or 5-10 x10⁹/L.

• Critical WBC: <2,000 or >40,000/mm³ or <2 or >40x10⁹/L.

• PT: 11-12.5 seconds (normal) or  ≥1.5-2 x control (with anticoagulant therapy)

• aPTT: 30-40 seconds (normal) or  ≥1.5-2.5 x control (with anticoagulant therapy)

• INR: 0.8 - 1.1 (normal) or 2 - 3 (for A - fib) or  3 - 4.5 (for prosthetic valves)

NCLEX Mastery provides lab reference ranges from Mosby’s, 5th Edition (2013) and Mosby’s Canadian (2012). In a few instances, SI ranges have been sourced from Stedman’s Online or conversions made from Mosby’s conventional values, calculated using the AMA Manual of Style SI Conversion Calculator.

For a complete lab resource, broken down by gender and age group, consult any of our nursing apps.

NCLEX Pharmacology Medical Suffixes

-amil = calcium channel blockers

-caine = local anesthetics

-dine = anti-ulcer agents (H2 histamine blockers)

-done = opioid analgesics

-ide = oral hypoglycemics

-lam = anti-anxiety agents

-oxacin = broad spectrum antibiotics

-micin = antibiotics

-mide = diuretics

-mycin = antibiotics

-nuim = neuromuscular blockers

-olol = beta blockers

-pam = anti-anxiety agents

-pine = calcium channel blockers

-pril = ace inhibitors

-sone = steroids

-statin =antihyperlipidemics

-vir = anti-virais

HCG has a structural similarity to TSH. Some testicular tumours have increased levels of HCG which may stimulate TSH receptors and cause hyperthyroidism.

Hyperrespiration and hyperventilation are different in that “increased ventilation” means using the respiratory zone (increased depth) which means you’re blowing off more CO2 whereas hyperrespiration means that you’re breathing rapidly (increased respiration rate) and shallow (decrease in depth) which means that you are not using the respiration zone and are only using the conducting zone which also means retaining more CO2 and therefore hypoventilation . In other words hyperrespiration results in hypoventilation.

Normal A-a gradient MCC of hypoxemia and hypoventilation.

The most important mitochondrial diseases are myoclonic epilepsy with ragged

fibers and leber optic neuropathy and mitochondrial encephalopathy and since mitochondria in sperm cannot be passed into the ovum during fertilization : males cannot transmit mitochondrial dzs.

Positive stool guiac test (detects bleeding GI tract) = PUD

MC location of PUD= proximal duodenum and antral stomach and gastroesophageal junction and are d/t h.pylori and NSAIDS.

Isoniazid may be used as a mono therapy may be used for patients who have +ve PPD and a -ve CXR

Active TB should never be txd with Isoniazid mono therapy because results in rapid resistance and therefore selective survival of bacterial cells secondary to gene mutation

adding clavulanic acid (beta lactamase inhibitor) with amoxicillin (beta lactamase susceptible) decreases amoxicillin cleavage by bacterial cells thereby expanding amoxicillin’s spectrum.

Clavulanic acid sublactam and tazobactam are beta lactamase inhibitors.

Probenecid is a compound that decreases the renal clearance of penicillins by inhibiting the tubular organic acid secretion system. This agent has been utilized to prolong the action of penicillin in some settings (because it decreases their clearance so stay around longer).

Sudden onset of tachypnea and chest pain in hospitalized patient= PE esp. if the patient has a recent surgery (induced a hypercoagulable state) and immobilization (venous stasis- stasis of bl.). Hypoxemia in patients with PE develops d/t ventilation- perfusion mismatch

All skin from umbilicus down, including anus (up to the dentate/pectinate line) but excluding the posterior calf drains to the superficial inguinal lymph nodes.

LN from sigmoid colon drains to inf. Mesenteric LNS

LN from superior portion of bladder drain to external iliac nodes while lymph from inferior portion of bladder drains to internal iliac nodes.

Treatment failure for MRSA with methicillin is d/t poor interaction with binding proteins

Resistance to tetracycline and sulphonamides is d/t at least in part to decrease in the levels of drug accumulation d/t decreased uptake and or increase efflux

Mutations in DNA gyrase (topoisomerase) cause resistance to quinolone antibiotics.

Mutation in RNA polymerase causes resistance

VIP causes relaxation of GI smooth muscle, and inhibition of gastric acid secretion and stimulation of pancreatic bicarbonate and cl- secretion

Somatostatin decreases production of GI hormones and its inhibition of VIP production by VIP oma (increase in VIP secretion) is therefore reliving symptoms of patients with VIP oma.

CCK- increases secretion of pancreatic enzymes and bicarbonate, gall bladder contraction, and inhibition of gastric emptying. It’s produced by the I-cells o the proximal sm. Bowel mucosa in response to fatty acids and monoglycerides.

Secretin is produced by duodenal S-cells in response to duodenal acidity and fatty acids. It increases pancreatic and biliary bicarbonate secretion and decreases gastric acid secretion

gastrin is produced by G-cells in the stomach mucosa. It stimulates gastric acid production and growth of the gastric mucosa. Gastrinomas classically cause intractable PUD aka ZE syndrome

Glucagonoma is a pancreatic alpha- cell tumour that hypersecretes glucagon. Secondary DM can result.

Measuring urinary Cl- concentration and determining the patient’s volume status helps to identify the cause of metabolic alkalosis.

MCC of metabolic alkalosis is due to loss of Cl- ions via vomiting which causes an individual to lose excessive Cl- ions therefore making the patient hypochloremic and this means that thre would a significant decrease in urinary Cl-.

High potassium conductance and some sodium conductance forms the resting membrane potential of the cell.

Carotid massage and the valsalva manouever increase the parasympathetic tone which therefore slows the heart therefore prolonging the conduction through AV node and refractory period.

Paroxysmal SVT is a common dysrhythmia that frequently occurs in patients with no other heart dz. The cause is typically a re-entrant circuit in AV node. Episodes are usally treated w/ adenosine in hospital setting, but vagal manoeuvres such as carotid sinus massage and valsalva can be used.

Haloperidol commonly used in tx of agitation and MC a/w NMS

NF-1 is a single gene autosomal dominant disorder which occurs d/t mutation of NF-1 gene located on chromosome 17

tetrodotoxin is a potent neurotoxin found in pufferfish, functions by inhibition of voltage gated sodium channels in nerve cell membrane. It also inhibits passive transport of sodium

verapamil blocks L- type calcium channels thereby inhibiting passive transport of calcium ions in cardiomyocytes

lidocaine- Class 1B blocks voltage gated sodium channels in sensory neurons purkinje fibers and ventricular cells

dofetilide is a class III anti arrhythmic that blocks passive transport of potassium specifically the delayed outward current rectifier potassium current, in cardiomyocytes leading to prolongation of refractory period and of QT interval

omeprazole and other PPIs suppress the activity of gastric parietal cell H/K ATPase leading to increase in pH of gastric lumen.

What is the NCLEX-RN

The NCLEX-RN or National Counsel Licensing Exam for Registered Nurses is a standardized exam that all nurses in North America, and many other countries, must take before they can work as a Registered Nurse. The test is taken after graduating from a Bachelor of Science in Nursing.

The test uses Computerized Adaptive Testing (CAT) to score the exam. The NCSBN illustrates how CAT is used, and why it works for the NCLEX through the following explanation: 

Why CAT? CAT is used for the NCLEX because it:

Reduces the number of “easy” items that high-ability candidates receive; “easy” items tell little about a high performing candidate’s ability

Reduces the number of “difficult” items low-ability candidates receive; candidates tend to guess on items that are too difficult which can skew results

Reduces item exposure and subsequent security risks

Improves precision of measurement of the NCLEX candidate’s ability related to nursing and

Provides a valid and reliable measurement of nursing competence

How Does CAT Work?

Every time you answer an item, the computer re-estimates your ability based on all the previous answers and the difficulty of those items.

The computer then selects the next item that you should have a 50% chance of answering correctly.

This way, the next item should not be too easy or too hard

The computer’s goal is to get as much information as possible about your true ability level

You should find each item challenging as each item is targeted to your ability

With each item answered, the computer’s estimate of your ability becomes more precise.

(Source)

The NCLEX decides if the test taker passes or fails based on the following three caveats: 

1. 95% Confidence Interval: Questions 1-75 are evaluated to determine if you passed or failed based on if your answers fell above (right answer) or below (wrong answer) the 95% confidence interval (red line on the chart).  If a pass/fail cannot be determined by this measure (because there were some questions above and some below the confidence interval) then the next evaluation criteria would be used.

2.  Maximum Length Exam Rule: If the 95% confidence level is too close to determine a pass or fail then the computer will allow you to continue answering questions, up to question 265.  The first 60 questions are disregarded, and the pass or fail determination depends on questions 75-265. These questions are still judged by if they fall above or below the 95% confidence interval, but they may give a clearer picture than the first grading test because there are more items to answer.

3. Run Out of Time Rule: The NCLEX-RN exam has a maximum time limit of 6 hours. If the pass/fail determination has not been decided by the 6 hour mark then the last 75 questions will be graded to determine pass/fail. If all of the last 75 questions are correct, then you pass. If even one is wrong, then you fail.

Read more about the NCLEX-RN format and grading scheme here.

How Do I Prepare:

Here are some resources compiled by the University of North Carolina (Source):

NCLEX Review Resouces Here are some current review materials to help you prepare for NCLEX. An NCLEX review book is a helpful tool to have throughout the curriculum as it provides additional practice with multiple choice test items.

Saunders’ Comprehensive Review for the NCLEX-RN by Silvestri, 6th edition

Saunders Q & A Review for the NCLEX-RN Examination by Silvestri, 6th edition

Saunders 2014-2015 Strategies for Test Success – Passing Nursing School and the NCLEX Exam by Silvestri, 3rd edition

Saunders Q&A Review Cards for the NCLEX-RN Examination by Silvestri and Silvestri, 2nd edition

Davis’s NCLEX-RN Success by Lagerquist, 3rd edition

Davis’s Q & A for the NCLEX-RN Examination by Ohman, 2010

Mosby’s Comprehensive Review of Nursing for the NCLEX-RN Exam by Nugent et al., 20th edition

Kaplan NCLEX RN 2013-2014 Edition: Strategies, Practice, and Review

Lippincott’s NCLEX-RN Review Made Incredibly Easy, 5th edition

Lippincott’s NCLEX-RN Questions and Answers Made Incredibly Easy, 5th edition

Lippincott’s NCLEX-RN Alternate-Format Questions, 4th edition

Mobile Apps

ATI Mobile Mentor

HESI Q&A for the NCLEX-RN Exam

Saunders Mobile Review Questions for the NCLEX-RN Exam

Saunders Mobile Review Questions for the NCLEX-RN Exam Lite (FREE)

Tips for Buying NCLEX Review Materials

Purchase the most current edition. The NCLEX test plan changes periodically and your review book should be consistent with the latest test plan.

Many books have CD’s with extra questions or may provide links to extra questions on-line. The more practice questions you do, the better prepared you will be for the NCLEX exam.

Question and answer books should include rationale for each answer; look for resources that also include other helpful information with each question, such as testing strategies.

And finally, here are some of the (FREE) resources that I’ve compiled from around the web:

NCLEX Studying and Test Taking Strategies

When it comes to studying, remember to do what works for you. If you are a visual learner, get a white board and draw the physiology diagrams. If you prefer to listen find books on tape, audio lectures, or find other audio learners in your program and get together to study by explaining question rationales to each other. 

Brilliant Nurse - NCLEX Strategies and Study Tips Blog

How to Pass the NCLEX-RN Exam

Tips from Grads for Preparing for the NCLEX

NCLEX Mastery App (free)

Nursing Show -Breaking Down NCLEX Questions

Free Practice Tests and Sample Questions

Practice tests are key. The questions on the NCLEX are known to be a bit different to the multiple choice you are used to. First, understand how to answer multiple choice questions (see this resource if you need help with that). Then use these resources and time yourself to get an idea of how your body will react to the pressure of being timed.

Mighty Nurse - NCLEX and HESI Practice Questions

4Tests - Free NCLEX Practice Exam

Test Prep Review - NCLEX Practice Test Questions

NCLEX Practice Quiz and Study Questions

Brilliant Nurse - 75 Free NCLEX Questions

Study Guide Zone - NCLEX RN Study Guide

Quizlet - NCLEX Questions

Tests.com - Free NCLEX-RN Practice Test

ProProfs Webschool - NCLEX 150 Questions, Answers and Rational

RNpedia.com - NCLEX Exam

NCLEX-RN Review

Exams for Nursing

NCLEX-RN Exam Cram

Nurse Labs - NCLEX Practice Questions

Remember, as with everything on the internet, use with caution. Just because a website states something as true, it does not mean that it is the most correct answer. The idea behind providing these links is to guide your studying and to gain a feeling for the style of the NCLEX questions.

Know your Airborne, Droplet and Contact precautions. I had many questions based on precautions on my test. This was how I learned them for the test.

AIRBORNE PRECAUTIONS:

Airborne = MTV

Measles

TB 

Varicella - Chicken Pox / Herpes Zoster - Shingles

TB

Private Room, Negative pressure with 6-12 air exchanges/hr and mask.

N95 mask for TB patients.

DROPLET PRECAUTIONS:

For Droplet precautions think of SPIDERMAN

S - Sepsis

S - Scarlet fever

S - Streptococcal pharyngitis

P - Parvovirus B19

P - Pertussis

P - Pneumonia

I - Influenza

D - Diptheria (pharyngeal)

E - Epiglottitis

R - Rubella

M - Mumps

M - Mycoplasma / Meningeal pneumonia

M - Meningitis

AN - Adenovirus 

Private room, mask.

You can keep the door open with patients who are on droplet precautions.

CONTACT PRECAUTIONS:

For Contact precautions think of MRS. WEE!

M - Multidrug resistant organism (MRSA)

R - Respiratory infection

S - Skin infections**

W - Wound infection

E - Enteric infection (Clostridum Difficile)

E - Eye infection (Conjunctivitis) 

Skin Infection (VCHIPS)

V -Varicella Zoster

C - Cutaneous Diptheria

H - Herpes Simplex

I - Impetigo

P - Pediculosis

Ventricular Tachycardia (V-Tach)

Ventricular Tachycardia is a dysrhythmia that usually originates from a single site within the ventricles at a rate greater than 100 bpm. The QRS complex is wide, bizarre and >0.12 seconds. As the heart rate increases, the ventricles do not have the opportunity to completely empty and refill. Therefore, cardiac output is decreased and adequate amounts of blood are not circulated to vital organs. Once the heart rate exceeds 160 impulses per minute, there is usually no effective pumping action of the heart and the patient presents with PULSELESS V-Tach. This patient requires immediate defibrillation. It is possible to have a pulse with V-Tach, however this will degrade into a life threatening dysrhythmia if left untreated.

  Ventricular Fibrillation (V-Fib)

NOTE: 

Antidote for Coumadin = VITAMIN K thus.. if a patient is on coumadin tell them not to ingest any foods with vitamin k (dark leafy greens) as it will decrease coumadins effectiveness, likewise, if a patient has had too much coumadin and is bleeding, we administer vitamin K to reverse!

Antidote for Heparin is Protamine sulfate, if a patient has had too much heparin and is bleeding this is what we administer.

FOR COUMADIN check PT levels