20

25
 Archer Review

Table of Contents
Introduction Part III: Specialties

1 General How To: Zoom and Slido 143 Maternity

2 Taking Effective Notes/Copyright 152 Labor and Delivery

3 Welcome to Archer Review 159 Pediatrics

174 Mental Health

Part I: Building Blocks

Part IV: Wrap-Up
4 Introduction to the NCLEX

6 Foundations Part 1: ABGs 186 Test-Taking Strategies

11 IV Fluids 188 Mock NCLEX

12 Foundations Part 2: Electrolytes 195 Score Sheet

196 Mock NCLEX Answer Key

Part II: System-by-System
25 Cardiovascular System
Next Steps
42 Respiratory System 202 You Finished the 3-Day Live Review
61 Prioritization
203 6-Week Study Plan
68 Introduction to Day 2
204 12-Week Study Plan
69 Nervous System
205 Daily Planner
88 Gastrointestinal System

104 Renal System

114 Shock

121 Endocrine

142 Introduction to Day 3

 Archer Review

General How To: Zoom and Slido

Receive the Invitation:
A Zoom invitation from Archer Review Webinars will be sent to the email
you registered for the 3-Day Live Review with. It will also be in your
Archer Review dashboard. Make sure you have the date and time of the
webinar handy.

Prepare Your Device:

Please ensure your computer, tablet, or smartphone is charged or
connected to a power source. You'll need a stable internet connection.

Download the Zoom App:

If you have not installed the Zoom desktop app, you may be prompted
to download and install it when you click the webinar link. You can
follow the on-screen instructions to do that. Alternatively, you can
join the webinar from your web browser, but using the app often
provides a better experience.

Join the Webinar:

Click the webinar link provided in the invitation. You will be admitted
to the webinar by the host when it begins.

Chat and Q&A:

You can use the Q&A feature to communicate with the panelists if you
have questions or comments. We will address questions
at specific points during the webinar.

Leave the Webinar:

When the webinar concludes or when you need to leave, you can
simply exit the Zoom meeting.

Slido:
You can join Slido by scanning the QR code provided during the
presentation or by going to Slido.com and typing in the provided
code for each day.

1
 Archer Review

Taking Effective Notes

During the 3-Day Live Review

Effective NCLEX preparation requires thorough review and note-taking.

Follow these tips to make the most out of your note-taking process:

Come Prepared:
Before the review, please be sure to familiarize yourself with the basic
concepts and topics we will cover. Having a foundational understanding
will help you take more meaningful notes.

Active Listening:
Pay close attention to the instructors during the live review. Engage
actively with the material and listen for key points, essential concepts,
and keywords.

Highlight Key Information:

Use highlighters, underlines, or bold text to emphasize important
information in your notes. This makes it easier to review and study
later on. When you see a you need to fill in the answer.
Bolded items and items in red are extra important!

Review and Summarize:

After each day of the live review, take some time to review your notes.
Summarize the main points and concepts in your own words. This
reinforces your understanding and helps with retention.

Copyright Information
© 2023-2024 USMLE Galaxy LLC. All rights reserved. No part of this
book may be reproduced or used in any manner without the prior written
permission of the copyright owner. To notify the publisher of suspected
copyright infringement, please contact support@archerreview.com.

2
 Archer Review

Welcome to Archer Review: Your Learning Hub

Breaks:
We've scheduled 15-minute breaks throughout the course
to give you time to recharge and refocus. We've set aside 45 minutes
for lunch for a more extended break. It's time to step away, enjoy a meal,
and relax. Remember, it's okay to step away whenever you need to.
Your well-being is important to us!

Optional Q&A:
At the end of Day 1 and Day 2, we host optional Q&A sessions.
It's a chance to get answers to your questions and clarify any doubts.

Recording:
Good news for SurePass combo purchasers! This lecture will be
updated in your Archer Review dashboard for OnDemand streaming
within one week. Your learning continues even after the live session ends!

You will not get access to the recordings if you only purchased
the 3-Day Live Review.

Questions:
Do you need technical support or have questions about streaming,
handouts, or anything else? We're here to help! Reach out to us at
support@archerreview.com.

If there are any nursing-related questions not answered in the

3-Day Live Review, they can be sent to nclextutors@archerreview.com.

We're excited to embark on this learning journey with you. Feel free
to reach out if you have any questions or need assistance.
Let's make this an enriching experience together!

Best regards,
The Archer Review Team

3
 Archer Review

N ot es
Q U E S T I O N S

D E T A I L S

DAY 1 SCHEDULE
9 AM - 4 PM CT
TIME TOPIC
9:00 - 9:25 AM Welcome/Test Plan/Intro
9:25 - 10:15 AM Foundations (Part 1)
S U M M A R Y
10:15 - 10:25 AM Break
10:25 - 11:15 AM Foundations (Part 2)
11:15 - 11:25 AM Break
11:25 - 12:15 PM Cardiac (Part 1)
12:15 - 1:00 PM Lunch
1:00 - 1:50 PM Cardiac (Part 2)
1:50 - 2:00 PM Break
2:00 - 3:10 PM Respiratory
3:10 - 3:20 PM Break
K E Y T E R M S
3:20 - 3:40 PM Prioritization
3:40 - 4:00 PM Test Anxiety

Success is the sum of small efforts,

repeated day in and day out. Every
moment you invest now brings you
one step closer to your goal.
4
 Archer Review

Part I: N ot es
Building Blocks Q U E S T I O N S

D E T A I L S

S U M M A R Y

Have you spent more time memorizing or

understanding content during your NCLEX prep?

Write your answer here: K E Y T E R M S

5
 Archer Review

Foundations Part I N ot es
Q U E S T I O N S

ABG Interpretation
Get it right, every time!

D E T A I L S
The body likes the pH to be 7.35-7.45

If it gets higher or lower than this, it tries to bring it back into normal range!
This is called compensation

Metabolic Respiratory
Kidneys make bicarbonate, a base There are Lungs either retain, or blow off, CO2
More bicarb more alkalotic TWO More CO2 more acidotic
(pH goes HIGHER) (pH goes LOWER)
ways to
Less bicarb more acidotic Less CO2 more alkalotic
compensate
(pH goes LOWER) (pH goes HIGHER)

Normal Values
S U M M A R Y
pH 7.35-7.45

Bicarbonate (HCO3) 22-28

HCO3 = BASE metabolic

CO2 35-45

CO2 = ACID respiratory

STEP 1 Acidotic or Alkalotic?

K E Y T E R M S

Uncompensated Compensated Compensated Uncompensated

acidosis acidosis alkalosis alkalosis
<7.35 7.35 -7.39 7.41 -7.45 >7.45

7.4
perfect!
6
 Archer Review

STEP 2 Respiratory or Metabolic? Notes

Q U E S T I O N S
CO₂ problem = HCO₃ problem =
Respiratory Metabolic

D E T A I L S

Respiratory Respiratory Metabolic Metabolic

Acidosis Alkalosis Acidosis Alkalosis
Too much CO₂ Not enough CO₂ Not enough HCO₃ Too much HCO₃
Hypoventilation Hyperventilation Renal Too much
Overdose Panic attack disease sodium bicarb
COPD Loss of Antacids
Asthma bicarb Vomiting
Diarrhea

STEP 3 Compensated or Uncompensated? S U M M A R Y

Wait… partial or fully compensated? K E Y T E R M S

7
 Archer Review
Question 1
Your client has the pH 7.58
N ot es
following arterial Q U E S T I O N S
blood gas values. CO₂ 35

HCO₃ 41
StepAcidosis
#1: Acidosis or alkalosis?
or alkalosis?
7.58 > 7.45 Alkalosis
7.58 > 7.45 Alkalosis. D E T A I L S
StepRespiratory
#2: Metabolic or respiratory?
or metabolic?
The HCO₃ is too high, causing a metabolic alkalosis.
The HCO₃ is too high, causing a metabolic alkalosis.

StepCompensation?
#3: Compensated or uncompensated?
The CO₂ is normal - not helping! Uncompensated.
The CO₂ is normal - not helping! Uncompensated.

Answer: Uncompensated Metabolic Alkalosis

Knowledge Check!
Question 2
S U M M A R Y
A client presents with the following ABG results.
What is the correct interpretation?
a. pH: 7.23
b. CO₂: 67
c. HCO₃: 28
Answer:
Acidosis or alkalosis?
pH <7.4 Acidosis.

Respiratory or metabolic?
The CO₂ is high. CO₂ is an acid. High acid causes acidosis. CO₂ is causing the problem
Respiratory.

Compensation?
Since CO₂ is causing the problem, look to HCO₃ and see if it is trying to help. The HCO₃
is normal, it is not helping, so this is uncompensated.

Question 3
A client presents with the following ABG results.
What is the correct interpretation? K E Y T E R M S
a. pH: 7.37
b. CO₂: 80
c. HCO₃: 42
Answer:
Acidosis or alkalosis?
pH <7.4 Acidosis.

Respiratory or metabolic?
The CO₂ is high. CO₂ is an acid. High acid causes acidosis. CO₂ is causing the problem
Step #1: Acidosis or Alkalosis?
Respiratory.
pH is normal.
Compensation?
Step #2: Respiratory or metabolic?
TheSince
CO₂CO₂is normal. The
is causing theHCO₃ is normal.
problem, look to HCO₃ and see if it is trying to help. The HCO₃
Step #3: Compensation.
is high. HCO₃ is a base. Lots of base raises our pH. This is helping the problem - so the
Notgas
needed…. Everything
is compensated. is normal!
Partially or fully? Look at the pH! It is within the normal range, so
the HCO₃ has fully fixed the problem. This is a fully compensated blood gas. 8
 Archer Review
Question 4
A client presents with the following ABG results.
What is the correct interpretation?
a. pH: 7.58
N ot es
b. CO₂: 48 Q U E S T I O N S
c. HCO₃: 38
Answer:
Acidosis or alkalosis?
pH >7.4 Alkalosis.
D E T A I L S
Respiratory or metabolic?
The CO₂ is high. CO₂ is an acid. High acid causes acidosis. The HCO₃ is high. HCO₃ is a
Step base.
#1: Acidosis
A high baseor causes
Alkalosis?
alkalosis. We have an alkalosis, so the HCO₃ is causing the
pH <7.4 Acidosis
problem. When HCO₃ is the problem, it is metabolic.
Step #2: Respiratory or metabolic?
Compensation?
The CO₂ is high. CO₂ is an acid. High acid causes acidosis. CO₂ is causing the
Since HCO₃
problem is causing the problem, look to CO₂ and see if it is trying to help. The CO₂ is
Respiratory.
Step high. CO₂ is an acid. High acid lowers the pH, and the current pH is too high. This is
#3: Compensation.
Sincehelping
CO₂ isthe problem - so the gas is compensated. Partially or fully? Look at the pH! It is
causing the problem, look to HCO₃ and see if it is trying to help. The
NOT within the normal range, so the CO₂ has only partially fixed the problem. This is a
HCO₃partially
is normal, it is not helping, so this is uncompensated.
compensated blood gas.

Question 5
A client presents with the following ABG results.
What is the correct interpretation?
a. pH: 7.43
b. CO₂: 51
c. HCO₃: 42 S U M M A R Y
Answer:
Acidosis or alkalosis?
pH >7.4 Alkalosis.

Respiratory or metabolic?
The CO₂ is high. CO₂ is an acid. High acid causes acidosis. The HCO₃ is high. HCO₃ is a
Step #1: Acidosis
base. A highorbase
Alkalosis?
causes alkalosis. We have an alkalosis, so the HCO₃ is causing the
pH <7.4 Acidosis
problem. When HCO₃ is the problem, it is metabolic.
Step #2: Respiratory or metabolic?
The CO₂ isCompensation?
high. CO₂ is an acid. High acid causes acidosis. CO₂ is causing the problem Respiratory.
Step #3: Compensation.
Since HCO₃ is causing the problem, look to CO₂ and see if it is trying to help. The CO₂ is
Since CO₂ is causing the problem, look to HCO₃ and see if it is trying to help. The HCO₃ is high. HCO₃ is a
high.ofCO₂
base. Lots baseisraises
an acid.our High acidis lowers
pH. This helpingthe
the pH, and the
problem - so current pHcompensated.
the gas is is too high. This is or
Partially
helping
fully? Look thepH!
at the problem - sothe
It is within thenormal
gas is range,
compensated. Partially
so the HCO₃ or fully?
has fully Look
fixed the at the pH.
problem. This Itis is
a fully
within the
compensated normal
blood gas. range, so the CO₂ has fully fixed the problem. This is a fully
compensated blood gas.

Question 6
A client presents with the following ABG results.
What is the correct interpretation?
a. pH: 7.62
K E Y T E R M S
b. CO₂: 14
c. HCO₃: 18
Answer:
Acidosis or alkalosis?
pH >7.4 Alkalosis.
Acidosis or Alkalosis?
pH >7.4Respiratory
Alkalosis or metabolic?

Respiratory
The CO₂ or is metabolic?
low. CO₂ is an acid. Low acid causes alkalosis. The HCO₃ is low. HCO₃ is a
The CO₂ isLow
base. high.base
CO₂ is an acid.acidosis.
causes High acidThe
causes
CO₂acidosis. The HCO₃
is causing is high. HCO₃Respiratory.
the problem is a base. A high
base causes alkalosis. We have an alkalosis, so the HCO₃ is causing the problem. When HCO₃ is the
Compensation?
problem, it is metabolic.
Since CO₂ is causing the problem, look to HCO₃ and see if it is trying to help. The HCO₃
Compensation?
is low.
Since HCO₃Low HCO₃the
is causing lowers thelook
problem, pH,to and
CO₂theandcurrent
see if it ispH is too
trying high.
to help. TheThis
CO₂isishelping
high. CO₂the
is an
problem
acid. High acid - lowers
so the the
gaspH, is and
compensated.
the current pHPartially or This
is too high. fully? Look atthe
is helping the pH! It -issoNOT
problem within
the gas
is compensated. Partiallyso
the normal range, orthe
fully? Look at
HCO₃ theonly
has pH! Itpartially
is NOT withinfixedthe thenormal range,This
problem. so the
is CO₂ has
a partially
only partially fixed the
compensated problem.
blood gas. This is a partially compensated blood gas.
9
 ANSWER KEY -
FOUNDATIONS PART 1
Base
Page 6 Acid
Acidotic or Alkalotic

Respiratory or Metabolic
Page 7
Compensated or Uncompensated

Uncompensated metabolic acidosis

Page 8 Uncompensated respiratory acidosis
Fully compensated respiratory acidosis

Partially compensated metabolic alkalosis

Page 9 Fully compensated metabolic alkalosis
Partially compensated respiratory alkalosis

Lactated Ringer’s
Page 11 Cerebral edema
Lactated Ringer’s

10
 Archer Review

IV Fluids
N ot es
Q U E S T I O N S
“The concentration of a solution as
Tonicity compared to another solution”
How much stuff is in this fluid…
compared to something else
D E T A I L S

Blood vs IV fluid
Isotonic IV Fluids
IV fluid with osmolarity similar to blood.
Isotonic Expand intravascular fluid volume and do NOT
cause a shift in fluid.

Lactated Ringers (LR)

Blood loss
0.9% Sodium Chloride (Normal Saline) S U M M A R Y
Surgery
Isotonic dehydration 5% Dextrose in Water (D5W)
Fluid loss
Maintenance fluids D5W is technically isotonic,
but it becomes hypotonic
Clients who are NPO
once in the body!

Hypotonic IV Fluids
IV fluid with osmolarity lower than blood.
Moves fluid out of blood vessels into cells and
Hypotonic
interstitial spaces.

0.45% Sodium Chloride (½ Normal Saline)

DKA 0.33% or 0.2% Sodium Chloride
HHNS 2.5% Dextrose in Water (D2.5W)
Hypernatremia 5% Dextrose in Water (D5W)
K E Y T E R M S

Hypertonic IV Fluids
IV fluid with osmolarity higher than blood.
Hypertonic Moves fluid out of cells and interstitial spaces
and into blood vessels.

1.5%, 3%, or 5% Sodium Chloride

D5NS
Hyponatremia
D5LR
Cerebral edema
D10W

Which type of fluid would you want to give

to a client who suffered from a burn injury? 11
 Archer Review

Foundations Part II N ot es
Q U E S T I O N S

Electrolytes
D E T A I L S
Sodium 135-145 mEq/L Magnesium 1.5-2.5 mg/dL
Potassium 3.5-5 mEq/L Chloride 98-106 mEq/L
Calcium 9-10.5 mg/dL Phosphorus 3-4.5 mg/dL

Sodium - Na+
Sodium 135-145 mEq/L
The most abundant extracellular cation
Regulates water in the cells of the body
Water follows sodium
Sodium is important in:
The brain
Nerves
Muscle cells

Hypernatremia S U M M A R Y

Two ways it can happen….

Recognize Cues K E Y T E R M S

12
 Archer Review

Take Action
N ot es
Q U E S T I O N S

D E T A I L S

Monitor neuro status

Key Correct imbalance SLOWLY
point!
Risk for cerebral edema

Hyponatremia S U M M A R Y

Two ways it can happen….

K E Y T E R M S

Recognize Cues

13
 Archer Review

Take Action
Notes
Q U E S T I O N S

D E T A I L S

High salt diet

Anything
processed! S U M M A R Y

Replacing sodium
Replace sodium slowly
0.5 mEq/hr
Changing the sodium level too quickly causes fluid shifts
Cerebral edema
Increased ICP

A client comes in with a sodium of 128 mEq/L.

What nursing intervention should you K E Y T E R M S

implement?

NCLEX Question
The nurse is caring for a client whose most recent serum sodium level was 152
mEq/L. Which of the following signs and symptoms do they suspect are caused by
the client's sodium level? Select all that apply.

a. Lethargy
b. Dry mucous membranes
c. Tachypnea
d. Cyanosis
e. Dry mouth

14
 Archer Review

Answer: A, B, and E
A is correct. Sodium plays a very important role in the brain, and imbalances in the
serum sodium level can cause major neurological changes. The client who is
N ot es
hypernatremic, or has a sodium level greater than 145 mEq/L is at risk for changes Q U E S T I O N S
in their level of consciousness ranging from restlessness and agitation to lethargy,
stupor, and coma.
B is correct. The client who has a high sodium level, greater than 145 mEq/L will
have dry mucous membranes. This is due to the relationship sodium has with
water. Water follows sodium, so where there is an increased level of sodium in the
extracellular space, water leaves the cells and follows the sodium into the D E T A I L S
extracellular space. This causes the dry mouth and mucous membranes.
E is correct. Dry mucous membranes are an expected finding in hypernatremia.
C is incorrect. Tachypnea, or an increased respiratory rate, is not a symptom of
hypernatremia. Sodium plays a very important role in the brain and nerves as well
as water balance. The major symptoms to monitor for will be neurological, not
respiratory.
D is incorrect. Cyanosis, or a bluish discoloration of the skin resulting from poor
circulation or inadequate oxygenation of the blood, is not a symptom of
hypernatremia. Sodium imbalance can cause many devastating neurological
symptoms, but will not result in cyanosis.

Chloride - Cl
Chloride 98-106 mEq/L

Most abundant extracellular anion

Sodium’s sidekick!
Works with sodium to maintain fluid balance S U M M A R Y
Binds with hydrogen ions to form stomach acid - HCl
Inversely related to bicarbonate
Directly related to sodium and potassium

Hyperchloremia
Causes Assessment Treatment

Fluid loss Signs and symptoms of Treat the underlying cause

Dehydration hypernatremia Correct the imbalance
Vomiting Bicarbonate
Sweating administration
Steroids Discontinue any sodium

Cl
Cushing’s Syndrome containing meds
Excess corticosteroid No NS for IVFs -
administration consider LR instead
Excess chloride Monitor all electrolytes -
administration it’s usually not the only
NORMAL SALINE! imbalance!

K E Y T E R M S

Hypochloremia
Causes Assessment Treatment

Volume overload Signs and symptoms of Treat the underlying cause

CHF hyponatremia
Water intoxication Correct the imbalance
Normal saline - 0.9% NaCl
Salt losses:
Burns

Cl
Monitor all electrolytes -
Sweating it’s usually not the only
Vomiting
imbalance!
Diarrhea
Cystic Fibrosis
Addison’s Disease
15
 Archer Review

Calcium - Ca
Calcium 9-10.5 mg/dL N ot es
Stored in the bones, absorbed in the GI system, and excreted by the kidneys Q U E S T I O N S
Plays an important role in bones, teeth, nerves, and muscles
Important for coagulation
Is controlled by parathyroid hormone and Vitamin D

Calcium and phosphorus have D E T A I L S

an inverse relationship!

Hypercalcemia Causes
Excessive intake of calcium
Hyperparathyroidism
Excessive intake of Vitamin D
Vitamin D toxicity
Cancer of the bones
Immobility

Recognize Cues
S U M M A R Y

Take Action
K E Y T E R M S

16
 Archer Review

Hypocalcemia Causes
Renal failure
Notes
Acute pancreatitis Q U E S T I O N S
Malnutrition
Malabsorption
Celiac disease
Crohn’s disease
Alcoholism
Bulimia D E T A I L S
Vitamin D deficiency
Hypoparathyroidism
Hyperphosphatemia

Recognize Cues

S U M M A R Y

Take Action
PO calcium supplements
Administer with Vitamin D
Vitamin D increases absorption of
calcium
IV calcium supplements
Calcium rich diet

Foods High in Calcium and Vitamin D

K E Y T E R M S

Calcium works
like a sedative!

17
 Archer Review

Phosphorus
Phosphorus 3-4.5 mg/dL Notes
Major role is in cellular metabolism and energy Q U E S T I O N S
production (ATP)
Makes up the phospholipid bilayer of cell membranes
Large component of bones and teeth
Has an inverse relationship with calcium
Calcium’s enemy!
D E T A I L S

Hyperphosphatemia

S U M M A R Y

Hypophosphatemia

Symptoms are
related to the
hypercalcemia
secondary to
hypophosphatemia.

Foods High in Phosphorus K E Y T E R M S

18
 Archer Review

NCLEX Question
The nurse is reviewing their clients' laboratory findings and notes that one of her
clients has a serum calcium level of 7.2 mg/dL. They know that of each of the
following clients, which ones are most likely to have this result? Select all that
N ot es
Q U E S T I O N S
apply.
a. The client with breast cancer and bone metastases
b. The client with obesity
c. The client with Vitamin D toxicity
d. The client with hypoparathyroidism
e. The client with chronic renal failure
D E T A I L S

Answer: D and E
D is correct. The client with hypoparathyroidism is most likely to suffer from
hypocalcemia. The normal calcium level is 9.0-10.5 mg/dL, so with this client's
level of 7.2 they have too little calcium in the blood. The client who experiences
hypoparathyroidism has too little parathyroid hormone (PTH). PTH regulates the
serum calcium concentration through its effects on the bones, kidneys, and
intestines. When there is too little PTH, there are decreased calcium levels, or
hypocalcemia.
E is correct. Hypocalcemia is a common problem in chronic renal failure and end-
stage renal disease (ESRD). There are two reasons for hypocalcemia in kidney
disease: increased phosphorus and decreased renal production of activated Vitamin
D (1,25 Dihydroxy vitamin D). Phosphorus accumulates in renal failure.
Hyperphosphatemia results in binding to calcium and precipitates as calcium
phosphate in tissues and bones, causing hypocalcemia. The kidney is responsible
for activating Vitamin D and restoring calcium balance. In the setting of renal
diseases, one loses the capacity to activate vitamin D and calcium level drops. For
these reasons, physicians often order phosphate binders to reduce phosphorus and S U M M A R Y
calcitriol (activated vitamin D, 1,25 Dihydroxy vitamin D) in chronic renal failure/
ESRD.
A is incorrect. The client with malignancy and bone metastases are more likely to
have hypercalcemia, not hypocalcemia. This is due to bone destruction from
osteoclasts and the leak of calcium into blood. In addition, malignancies often cause
"paraneoplastic hypercalcemia" by secreting substances called "PTH-related
peptides" that have actions similar to Parathormone ( PTH).
B is incorrect. Obesity is not a risk factor for hypocalcemia. Malnutrition and
malabsorption, such as in celiac and crohn’s disease clients, can cause
hypocalcemia due to decreased absorption, but obesity would not cause this.
C is incorrect. The client with Vitamin D toxicity would put a client at risk for
hypercalcemia, or a serum calcium level greater than 10.5 mg/dL. This is due to the
relationship between Vitamin D and calcium; Vitamin D enhances the absorption of
calcium. Therefore, Vitamin D toxicity would lead to increased absorption of
calcium and a hypercalcemic state.

Magnesium - Mg
Magnesium 1.5-2.5 mg/dL
K E Y T E R M S
Stored in the bones and cartilage
Plays a major role in skeletal muscle contraction
Important for ATP formation
Activates vitamins
Necessary for cellular growth
Is directly related to calcium
Calcium’s friend!

Hypermagnesemia Causes
Excessive dietary intake
Too many magnesium containing medications
Over-correction of hypomagnesemia
Renal failure
19
 Archer Review

Recognize Cues
N ot es
Q U E S T I O N S

D E T A I L S

Take Action
Treat the cause
Hold any fluids or meds
containing magnesium
Loop diuretics
Calcium gluconate
Dialysis

Hypomagnesemia Causes S U M M A R Y

Alcoholism
Malnutrition
Malabsorption
Hypoparathyroidism
Hypocalcemia
Diarrhea

Recognize Cues

K E Y T E R M S

Take Action
Treat the cause
Monitor cardiac rhythm
Administer magnesium
PO - Magnesium hydroxide
IV - given very slowly

20
 Archer Review

NCLEX Question
The nurse is caring for a client with a serum magnesium level of 3.2 mg/dL. they
know that which of the following could have caused this electrolyte abnormality?
N ot es
Select all that apply. Q U E S T I O N S

a. Renal failure
b. Alcoholism
c. Anorexia
d. Diarrhea
e. Malnutrition D E T A I L S

Answer: A
A is correct. The normal magnesium level is 1.5-2.5 mg/dL. This client has a level
of 3.2, and is experiencing hypermagnesemia. Renal failure can cause
hypermagnesemia due to the fact that the process that keeps the levels of
magnesium in the body at normal levels does not work properly in people with
kidney dysfunction.
B is incorrect. Alcoholism is a risk factor for hypomagnesemia, and this client has
hypermagnesemia. Hypomagnesemia is the most common electrolyte abnormality
observed in alcoholic clients. There is a loss of magnesium from tissues and
increased urinary loss, and chronic alcohol abuse depletes the total body supply of
magnesium.
C is incorrect. Anorexia is a risk factor for hypomagnesemia, and this client has
hypermagnesemia. This is due to malnutrition and a lack of dietary intake of
magnesium.
D is incorrect. Diarrhea is a risk factor for hypomagnesemia, and this client has
hypermagnesemia. Magnesium is absorbed in the GI tract, and with diarrhea there S U M M A R Y
is decreased absorption of magnesium leading to hypomagnesemia.
E is incorrect. A client who is malnourished will have had a poor dietary intake of
magnesium, leading to hypomagnesemia.

Torsades de Pointes is seen on the EKG,

the nurse should prepare to IV push

Potassium - K
Potassium 3.5-5 mEq/L

Found mostly inside the cells - most abundant

intracellular cation.
Normal value is for serum level - the potassium
in the blood, outside of the cells.
Responsible for nerve impulse conduction
Important in muscle contraction - heart muscle
and skeletal muscle. K E Y T E R M S
Important in acid-base balance
Acidotic increased K+

Hyperkalemia Causes
Too much potassium moved from intracellular to extracellular
Burns
Tissue damage
Diabetic ketoacidosis
Too much total potassium
Renal failure
Excessive K+ intake
Medications
ACE inhibitors
Potassium-sparing diuretics 21
 Archer Review

Recognize Cues Hyperkalemia

Muscle weakness
Numbness
Signs & Symptoms N ot es
Shallow respirations
"MURDER" Q U E S T I O N S
Cramping
Muscle cramps
Hyperactive bowel sounds
Urine abnormalities
Diarrhea
Respiratory distress
Impaired contractility CO
Decreased cardiac contractility D E T A I L S
Weak pulses
Bradycardia
E KG changes
Hypotension Reflexes (depressed/absent DTRs)
EKG CHANGES

EKG Changes
Wide, flat P waves
Prolonged PR interval
Widened QRS interval
Depressed ST segment
Tall, peaked T waves

Analyze Cues: Can lead to V-Fib or heart

block or eventually cardiac arrest!
S U M M A R Y

Take Action
Interventions depend on severity of hyperkalemia and the symptoms present
MONITOR CARDIAC RHYTHM Drive potassium into cells
Discontinue any potassium D5W + regular insulin
supplements Albuterol
IV potassium Bicarbonate
PO supplements Reduce total body potassium
Potassium restricted diet Kayexalate
IV Calcium gluconate or chloride Diuretics
Given if EKG changes are Hydrochlorothiazide
present to protect the Furosemide
myocardium Dialysis
Used when severe
hyperkalemia is not
responding to other
interventions

Causes of Hypokalemia - "DITCH" K E Y T E R M S

Laxatives
D Drugs Diuretics
Corticosteroids
NPO Bulimia nervosa
I Inadequate K intake Poor diet Alcoholism
Anorexia nervosa

Polydipsia
T Too much water Excessive IVF administration

Too much cortisol

C Cushing's syndrome Retention of Na/Water
Secretion of K
NGT suction
Wound drainage
H Heavy fluid loss Vomiting
Sweating
Diarrhea

OTHER: Alkalosis, Hyperinsulinism 22

 Archer Review

Analyze Cues EKG Changes

Decreased deep tendon reflexes
Weakness
Flaccidity
Slightly peaked P wave
Slightly prolonged PR interval
ST depression
Notes
Q U E S T I O N S
Shallow respirations Flat/shallow/inverted T waves
Decreased bowel sounds Prominent u-waves
Constipation
Abdominal distention
Orthostatic hypotension
Weak, thready pulse
D E T A I L S
Cardiac dysrhythmias

Take Action
Prevent arrhythmias
Place on cardiac telemetry
Hold digoxin
Prevent further K+ loss
Hold furosemide or other potassium
wasting drugs
Give more potassium
IV Potassium supplements
Oral potassium supplements
Give with food to prevent GI upset
Diet rich in potassium

IV Potassium Supplement Administration S U M M A R Y

Give according to instructions; SLOWLY
Monitor IV site very carefully
Can cause phlebitis Never give
Extravasation will cause tissue damage potassium
IV push!

NCLEX Question
The nurse is evaluating their client's lab results and notes that the potassium is 5.5
mEq/L. They review the telemetry monitor, looking for which of the following signs?
Select all that apply.

a. Inverted T waves
b. Widened QRS interval
c. Tall, peaked T waves
d. Prominent U-waves
e. Prolonged PR interval Answer: B, C, and E
B is correct. A widened QRS interval is a very important EKG finding in
hyperkalemia. Other EKG changes clients may experience when they are K E Y T E R M S
hyperkalemic include wide, flat P waves, a prolonged PR interval, a depressed ST
segment, and tall, peaked T waves.
C is correct. Tall, peaked T waves is a hallmark sign of hyperkalemia on an EKG.
Remember this one - it is a very common topic for NCLEX questions!! Hyperkalemia
leads to serious arrhythmias, and can progress to heart block, ventricular fibrillation,
or even asystole if left untreated.
E is correct. A prolonged PR interval is one of the EKG changes that occurs with
hyperkalemia.
A is incorrect. The normal range for potassium is 3.5 - 5 mEq/L. This client is
experiencing hyperkalemia. In hyperkalemia, there are tall, peaked T waves.
Inverted T waves is a sign of hypokalemia.
D is incorrect. The normal range for potassium is 3.5 - 5 mEq/L. This client is
experiencing hyperkalemia. Prominent U-waves are a sign of hypokalemia, or a
potassium less than 3.5, not hyperkalemia.
A client comes in with a potassium
abnormality. What should the nurse do first? 23
 ANSWER KEY -
FOUNDATIONS PART 2
Brain Fluid loss
Page 12 Nerves Hypotension
Muscle cells Weak pulses

Page 13 3% NS administration Seizures

Page 14 processed slowly
vitamin D Deep vein thrombosis
Page 16
Immobility Cardiac monitoring
Renal Failure
Page 17 Chvostek’s sign
sedative
Calcium’s enemy
Page 18
hypocalcemia
D and E
Page 19
Caium’s friend!
sedative
Page 20 Alcoholism
Increased deep tendon reflexes
A
Page 21 Push magnesium fast!
increased K+
Page 22 EKG changes cardiac rhythm
Prominent U-waves
Hold digoxin
Page 23 Phlebitis
B, C, and E
Place on cardiac monitor

24
 Archer Review

Part II: N ot es
System by System Q U E S T I O N S

D E T A I L S

Anatomy + Physiology Cardiovascular Disorders

Blood flow through the heart Hemodynamics
Cardiac cycle Hypertension
Electrical conduction system Coronary Artery Disease
EKGs Myocardial Infarction S U M M A R Y
Heart Failure
Cardiac pharmacology

Complete Blood Count (CBC)

Coagulation Panel K E Y T E R M S
Activated partial Prothrombin Time (PT)
thromboplastin time (aPTT)
Tests the extrinsic coagulation cascade
Tests the intrinsic coagulation
Normal value: 10 - 12s
cascade
Not on anticoagulants: 30 - 40s International Normalized Ratio (INR)
On heparin, “therapeutic aPTT”: It is calculated from a PT and is used to
1.5-2.5x normal monitor how well warfarin is working
Not on anticoagulants: 0.9-1.2s
On warfarin, “therapeutic INR”: 2-3s

Memory trick: Count 10 letters! D-Dimer

D-dimer
Normal value: <500 ng/mL
25
 Archer Review

Cardiac Labs
Troponin Notes
Q U E S T I O N S
Troponins are a group of proteins found in skeletal and cardiac muscle
fibers that regulate muscular contraction
Troponin detected in the bloodstream indicates myocardial injury
Normal = 0-0.4

D E T A I L S

BNP

When there is fluid retention, the heart senses the need to pump harder to
move fluid forward, and releases BNP
Test for CHF
Normal <100

The Pathway of Blood

S U M M A R Y

Cardiac Cycle
Superior Aorta
vena cava
Pulmonary artery
Pulmonary Pulmonary
veins veins
K E Y T E R M S

Right atrium Left atrium

Right ventricle
Left ventricle
Inferior
vena cava

Which blood vessel

brings deoxygenated
blood to the lungs?
26
 Archer Review

EKGs Notes
Q U E S T I O N S

What the EKG means

D E T A I L S

P wave:
Atrial depolarization

QRS complex:
Ventricular depolarization

T wave:
Ventricular repolarization
S U M M A R Y

Electrical Conduction System

K E Y T E R M S

Normal Sinus Rhythm

P-wave Normal
PR Interval 0.12-0.20
QRS <0.12
Rate 60-100
Regularity Regular
27
 Archer Review

Sinus Tachycardia
Notes
Q U E S T I O N S

P-wave Normal Causes Interventions D E T A I L S

PR Interval 0.12-0.20 Caffeine Exercise Fix the cause
QRS <0.12 Fever Anxiety
Rate 100-150 Hypotension Drugs
Regularity Regular Volume depletion Pain

Sinus Bradycardia

P-wave Normal Causes Interventions

S U M M A R Y
PR Interval 0.12-0.20 Sleep Fix the cause
QRS <0.12 Inactivity Atropine
Rate <60 Very athletic Pacing
Regularity Regular Drugs
MI

Pacing
EDUCATION
DO
Keep a pacemaker identification card in your wallet
Take a bath and shower 48 hrs post PPM insertion THREE
Operate household appliances - it’s safe!
TYPES
Notify airport security of pacemaker

DON’T Transcutaneous
Transvenous
Apply pressure over the generator Permanent K E Y T E R M S
Wear tight clothing
Get lead wires wet (temporary pacemakers)
Get an MRI

Transvenous

Permanent
Transcutaneous
28
 Archer Review

Atrial Arrhythmias
Causes
Atrial Fibrillation
N ot es
Heart disease Q U E S T I O N S
MI
CHF
Pericarditis

Interventions D E T A I L S
Fix the cause
Cardioversion
Antiarrhythmics:
Amiodarone
Beta blockers:
Metoprolol
Calcium channel
blockers: Diltiazem Atrial Flutter

Supraventricular Tachycardia (SVT) CAN be life-threatening.

Some clients tolerate,
some do NOT!

S U M M A R Y

Causes Interventions
P-wave Hidden Fix the cause
Caffeine
PR Interval Immeasurable Cardioversion
CHF
QRS <0.12 Adenosine
Fatigue
Rate 150 or higher
Hypoxia
Regularity Regular
Altered pacemaker in heart

Ventricular Arrhythmias
Interventions
Ventricular Fibrillation
Ventricular
Fibrillation
Fix the cause
Defibrillate K E Y T E R M S
CPR
Causes Epinephrine
Both are MI, Ischemia, Hypoxia,
LIFE THREATENING! Acidosis, Hypokalemia, Ventricular
Tachycardia
Hypotension
Fix the cause
Pulse present
Cardioversion
Pulseless
Defibrillate
Ventricular Tachycardia CPR
Epinephrine

29
 Archer Review

Asystole LIFE
THREA -
TENING
!!! N ot es
Q U E S T I O N S

Causes Interventions D E T A I L S
P-wave None Fix the cause
PR Interval None Follows VT/VF Hypokalemia CPR
QRS None Acidosis Hypothermia Epinephrine
Rate None Hypoxia Overdose
Regularity N/A

Knowledge Check!
Answer key on the next page

Question 1

S U M M A R Y

a. Normal sinus rhythm

b. Sinus bradycardia
c. Atrial fibrillation
d. Sinus tachycardia

Question 2

a. Normal sinus rhythm

K E Y T E R M S
b. Ventricular tachycardia
c. Atrial fibrillation
d. Atrial flutter

Question 3

a. Ventricular tachycardia
b. Atrial tachycardia
c. Atrial fibrillation
d. Ventricular fibrillation 30
 Archer Review

Question 4 N ot es
Q U E S T I O N S

D E T A I L S

a. Supraventricular tachycardia
b. Ventricular tachycardia
c. Atrial tachycardia
d. Sinus tachycardia

Question 5

S U M M A R Y
a. Normal sinus rhythm
b. Sinus bradycardia
c. Atrial fibrillation
d. Sinus tachycardia

Question 6

a. Ventricular fibrillation
b. Atrial fibrillation
c. Atrial flutter
d. Ventricular tachycardia
K E Y T E R M S

EKGs ANSWER KEY

1. A - Normal sinus rhythm
2. C - Atrial fibrillation
3. A - Ventricular tachycardia
4. A- Supraventricular tachycardia
5. B - Sinus bradycardia
6. A - Ventricular fibrillation
31
 Archer Review

Cardiac Pharmacology N ot es
Q U E S T I O N S

Antihypertensives
ACE inhibitors Calcium Channel Blockers
Captopril Amlodipine
Enalapril Nifedipine D E T A I L S
Lisinopril Verapamil
Angiotensin II Receptor Blockers Diltiazem
Losartan Direct acting vasodilators
Hydralazine
Nitroglycerin

With all antihypertensives, we

Key should monitor blood pressure due
point!
to the risk for orthostatic
hypotension!

ACE inhibitors [-pril]

S U M M A R Y
enalapril, lisinopril, benazepril, catopril
Indications: Hypertension, CHF
Action: Blocks conversion of angiotensin I to angiotensin II, increases renin levels
and decreases aldosterone leading to vasodilation
Nursing Considerations:
Can cause a dry cough - should be discontinued if it does
Monitor BP
Contraindicated during pregnancy

Angiotensin Receptor Blockers

(ARBs) [-artan]
Therapeutic class: Angiotensin II receptor blocker (ARB)
Indications: Hypertension, DM neuropathy, CHF
Action: Inhibits vasoconstrictive properties of angiotensin II
Nursing Considerations:
Monitor BP
Monitor the client’s fluid levels (I/O’s)
Monitor renal and liver status K E Y T E R M S
Contraindicated during pregnancy

Calcium Channel Blockers [-dipine]

nifedipine, amlodipine, diltiazem, verapamil
Indications: Hypertension, angina, atrial fibrillation/flutter
Action: Blocks transport of calcium into muscle cells inhibiting excitation and
contraction, causes peripheral vasodilation
Nursing Considerations:
Avoid grapefruit
Blocks the enzyme involved in metabolizing calcium channel blockers
causing amlodipine levels to increase
Monitor BP - orthostatic hypotension
Can cause gingival hyperplasia
32
 Archer Review

NCLEX Question Notes

The nurse is providing discharge instructions to a client with accelerated Q U E S T I O N S
hypertension who has been newly started on Nifedipine. His home medications
include calcium supplements for osteoporosis, omeprazole for heartburn,
furosemide, and lisinopril. Which statement(s) by the client demonstrates the need
for additional teaching regarding Nifedipine? Select all that apply.

a. “My gums may swell because of this medication.”

D E T A I L S
b. “I will avoid getting up too quickly from sitting or lying position.”
c. “I will stop taking calcium supplements since they may negate the
effects of Nifedipine.”
d. “It is highly likely that I will get constipated from this drug”
e. “If I get cough and tongue swelling, I will hold Nifedipine”

Answer: C, D, and E
C is correct. The client should not stop taking their calcium supplements. There is
no evidence to say oral calcium supplements will reduce the effects of CCBs. Also,
this client needs calcium supplements for his osteoporosis. Therefore, this does not
reflect the correct understanding by the client and needs additional teaching.
D is correct. There is a less than 2% chance that the person can get constipated
from Nifedipine, it is not true that the client is highly likely to get constipated from
Nifedipine. Therefore, this statement does not reflect the correct understanding by
the client and needs additional teaching.
S U M M A R Y
E is correct. The client should not hold Nifedipine if they get a cough and tongue
swelling. Cough and tongue swelling (Angioedema) are common side effects seen
with ACE inhibitors, not with CCBs. The client is also on Lisinopril (ACEI), which
may lead to this side effect, so the nurse will need to explain this to the client.
A is incorrect. Gum/ gingival hyperplasia is a common side effect with extended-
standing use of Nifedipine.
B is incorrect. The client should avoid getting up too quickly from a sitting or lying
position. Because of peripheral vasodilation, Nifedipine causes postural or
orthostatic hypotension. So, the client should be aware of getting up slowly from
the lying/ sitting position so they do not become dizzy.

Beta Blockers
Propranolol
Atenolol
Metoprolol
Esmolol
Sotalol K E Y T E R M S

Beta-adrenergic Blockers [-olol]

metoprolol, propanolol
Indications: Hypertension, angina, arrhythmias, MI, cardiomyopathy, alcohol
withdrawal, anxiety
Action: Blocks beta receptors, decreases HR and lowers blood pressure; blocks
epinephrine and norepinephrine action beta-1 heart
Nursing Considerations: beta-2 lungs
Do not discontinue abruptly
Can mask the signs of hypoglycemia; important to monitor blood sugars
Caution with asthma and COPD; can potentially cause bronchospasm

33
 Archer Review

Antiarrhythmics
Amiodarone
Adenosine
Notes
Atropine Q U E S T I O N S

Adenosine
Therapeutic class: Antiarrhythmic
Indication: Supraventricular tachycardia
D E T A I L S
Action: Slows conduction through the AV node, interrupts re-entry pathways
through AV node, restoring normal sinus rhythm
Nursing Considerations:
There will be a period of asystole after administration
Warn the client - it will feel like someone kicked them in the chest!
Warn the family - they will flatline on the monitor!
Rapid push - or it will not work
Use with extreme caution in asthmatics

Atropine
Therapeutic class: Antiarrhythmic; anticholinergic
Indications: Excessive secretions, sinus bradycardia, heart block
Action: Inhibition of acetylcholine, increasing the HR, causing bronchodilation,
and decreases secretions
Nursing Considerations:
Monitor for urinary retention and constipation S U M M A R Y
Avoid in clients with glaucoma

Digoxin
Therapeutic class: Cardiac glycoside
Indications: Heart failure, atrial fibrillation, atrial flutter, cardiogenic shock
Action: Increases contractility of the heart (how strong the heart pumps)
Nursing Considerations:
Therapeutic level: 0.5-2ng/mL
Monitor for toxicity
Hypokalemia increases risk for toxicity: caution with loop diuretics
and licorice extract
HOLD the medication if HR is <60
Antidote: digoxin immune FAB

Early signs Late signs

K E Y T E R M S
Nausea & vomiting
Anorexia Bradycardia → arrhythmias
Vision changes - yellow/green halos

Monitor for these signs and symptoms and report

them to the primary health care provider early!

Critical Care Medications

Inotropes: increases contractility of the heart
digoxin, dopamine, dobutamine, milrinone
Vasopressors: causes vasoconstriction, increasing blood pressure
norepinephrine, epinephrine, phenylephrine, vasopressin

34
 Archer Review

Notes
Q U E S T I O N S

Hemodynamics D E T A I L S
Preload
Amount of blood returning to right side of the heart
Afterload
Pressure against which the left ventricle must pump to eject blood
Compliance
How easily the heart muscle expands when filled with blood
Contractility
Strength of contraction of the heart muscle
Stroke volume
Volume of blood pumped out of the ventricles with each contraction
Cardiac output
The amount of blood the heart pumps through the circulatory system in
a minute

Cardiac Output S U M M A R Y

WHY is cardiac output SO important?!

Tissue perfusion!
End organ function
Delivery of oxygen and nutrients to each and every cell in the body!
Poor cardiac output??
Decreased LOC (not enough blood flow to the BRAIN)
Chest pain, weak peripheral pulses (not enough blood flow to the
HEART)
Shortness of breath, crackles, rales (not enough blood flow to the
LUNGS)
Cool, clammy, mottled extremities (not enough blood flow to the SKIN)
Decreased UOP (not enough blood flow to the KIDNEYS)

CO = SV X HR

K E Y T E R M S

35
 Archer Review

Cardiac Disorders Notes

Q U E S T I O N S

Hypertension Hypertension Causes and Risk Factors

D E T A I L S

Hypertension Complications

S U M M A R Y

Treatment & Education

Medications Lifestyle
ACE inhibitors Weight loss
Beta Blockers Smoking
CCB cessation
Diuretics Less sitting
more walking
Diet
Low salt
Avoid caffeine and
alcohol

Coronary Artery Disease K E Y T E R M S

Complete plaque
The most common type of cardiovascular disease
blockage leading to
Common types lack of adequate
Chronic stable angina oxygen to the heart
STEMI and NSTEMI

Minimal plaque build up

36
 Archer Review

Chronic Stable Angina

Chronic disease caused by narrowing of coronary arteries and plaque build up
Notes
There are periods of decreased blood flow to the heart muscle Q U E S T I O N S
Decreased blood flow leads to decreased oxygen and ischemia
Ischemia causes chest pain

Treatment
Nitroglycerin D E T A I L S
Venous and arterial dilation → decreased
afterload → increased CO
Given sublingual
Administer 1 pill q5 minutes for 3 doses
Do not swallow
Keep in a dark bottle in dry, cool place
Expected side effect = headache

Myocardial Infarction
Assessment
Chest pain
Crushing
Radiating to left arm or jaw S U M M A R Y
Between shoulder blades
Epigastric discomfort/indigestion
Fatigue
Shortness of breath
Vomiting

What is a Myocardial Infarction?

Myocardial infarction = acute coronary syndrome = unstable angina
There is decreased blood flow to the heart, leading to decreased oxygen
Not only ischemia, but also necrosis
Goal is to act quickly and limit the damage

Treatment
Cath lab within 90 minutes for PCI
Percutaneous coronary intervention
K E Y T E R M S
Especially important if it’s a STEMI!
O: Oxygen
N: Nitroglycerin
T: Thrombolytics (if appropriate)
I: Antiplatelets (e.g., aspirin or other medications)
M: Monitoring and Medical care
E: EKG to assess heart activity

What is your priority nursing

action when your client Percutaneous Coronary
complains of chest pain? Intervention (PCI)

37
 Archer Review

Education N ot es
Quit smoking Q U E S T I O N S
Diet
Low fat
Low salt
Low cholesterol
Exercise
Avoid isometric exercises D E T A I L S
Walking is a good choice

NGN Practice Question

The nurse cares for a 56-year-old in the emergency department
experiencing epigastric pain, shortness of breath, and dizziness.

Nurses’ Notes
1900 – A 56-year-old female presents to the emergency department (ED) with
reports of epigastric pain, shortness of breath, and dizziness. The client reports that
the symptoms started eight hours ago and have progressively worsened. The client
arrives pale and diaphoretic. The client has a medical history of type II diabetes
S U M M A R Y
mellitus and stated that her blood glucose has been very high. The blood glucose
was taken, and it was 110 mg/dL.

Which five (5) client findings require follow-up by the nurse?

a. Reports of epigastric pain
b. Blood glucose of 110 mg/dL
c. History of diabetes mellitus type II
d. Reports of shortness of breath
e. Progressive worsening of symptoms
f. Reports of dizziness
g. Pale skin and diaphoresis

NGN Answer: A, D, E, F, G

Heart Failure K E Y T E R M S

The inability of the heart muscle to pump enough blood to

meet the body's needs for blood and oxygen

Often results as a complication of other diseases

#1 cause of HF is hypertension
Left-sided
Other causes:
Failure
Cardiomyopathy
Endocarditis
MI Right-sided
Two types: left and right Failure

38
 Archer Review

Left-sided Heart Failure N ot es

Left side of the heart cannot move blood forward to the body. Q U E S T I O N S
Blood is backing up in the LUNGS.
Assessment:
Pulmonary congestion
Wet lung sounds
Dyspnea D E T A I L S
Cough
Blood tinged sputum
S3
Orthopnea

S U M M A R Y

Treatment
DECREASE THE WORKLOAD OF THE HEART!
Primary strategy is to decrease afterload:
ACE Inhibitors
Arterial dilation decreased afterload Increased stroke volume
ARBS
Decrease BP decreased afterload Increased CO
Increase contractility
Digoxin
Diuresis
Client needs help reducing excess fluid Report rapid K E Y T E R M S
weight gain
(3 lb in a week
Education or 1-2 lb
Take diuretic medications in the AM overnight)
Monitor electrolyte levels while on diuretics
Low sodium diet
This helps decrease fluid
Elevate the HOB
Will help with breathing
Daily weight
What findings are
Same time consistent with right
Same scale sided heart failure?
Same clothes

39
 Archer Review

Aortic Aneurysms Notes

Q U E S T I O N S
Thoracic
A dilation of the aorta is typically aortic
caused by atherosclerosis, HTN, aneurysm
smoking, family history
Normal aorta
Abdominal
D E T A I L S
Most common
Abdominal, back pain
Gnawing/sharp pain
Thoracic
Shortness of breath
Hoarseness/struggling with
swallowing
Back pain
Rupture
Life-threatening Abdominal
Severe pain aortic
aneurysm
Do not palpate pulsating mass

Air Embolism S U M M A R Y

An air bubble blocks blood flow Left lateral

in the heart or lungs trendelenburg
position
Complication of central or arterial line
During insertion
Sudden desaturation:
suspect air embolism!
Line gets accidentally pulled out

Positioning:
Durant’s maneuver
Left lateral
trendelenburg
This should prevent an air
embolism from lodging in
the lungs - will stay in the
right heart K E Y T E R M S

You finished cardiac!

Keep up the great work!

40
 ANSWER KEY - CARDIAC
Page 25 2-3 seconds
Page 26 BNP pulmonary artery
Page 27 Atrial depolarization Ventricular depolarization Regular
Page 28 Pacing 100 - 150 it’s safe!
Atrial fibrillation Adenosine
Page 29
Atrial flutter Epinephrine
Page 32 discontinued if it does Contraindicated gingival hyperplasia
Page 33 C, D, and E hypoglycemia
Page 34 asystole glaucoma 0.5-2ng/ml 60
Page 35 contractility End organ function
>180/<120 mmHg High salt intake
Page 36
Heart failure Diuretics

Page 37 decreased 3 doses headache jaw necrosis Cath lab

Page 38 Low cholesterol A, D, E, F, G

Page 39 lungs body ACE inhibitors Daily weight
Page 40 Do not palpate a pulsating mass left lateral trendelenburg

41
 Archer Review

N ot es
Q U E S T I O N S

Respiratory
D E T A I L S

Anatomy + Physiology Respiratory disorders through case study

Gas exchange COPD
Breath sounds Asthma
Pneumonia
ARDS
Pulmonary embolism
Pneumothorax

S U M M A R Y
Respiratory System Anatomy

Gas Exchange Blood

capillary Alveolus

The delivery of oxygen from the lungs to the

bloodstream and the elimination of carbon K E Y T E R M S
dioxide from the bloodstream to the lungs.
Occurs in the alveoli through passive diffusion.

Terminology
Ventilation
Air movement in and out
of the lungs
Oxygenation
Oxygen in the
bloodstream
Perfusion
Oxygen in the tissues
42
 Archer Review

Work of Breathing
Nasal flaring
N ot es
How easy is it for the client to take a deep Q U E S T I O N S
breath? Supraclavicular retractions Accessory
muscle use
Retractions
Note location and severity
Location
Subcostal Intercostal retractions
Subcostal
Intracostal retractions D E T A I L S
Supraclavicular
Tracheal
Nasal flaring
Head bobbing Cyanosis
Grunting

Let’s meet our client!

S U M M A R Y

AGE 14

5' 2'' 112 lbs RA

Asthma

What is Asthma? K E Y T E R M S

A respiratory condition marked by spasms in the bronchi

of the lungs, causing difficulty breathing

Chronic inflammation of bronchi and

bronchioles
Excess mucus
Result of an allergic reaction or
hypersensitivity

43
 Archer Review

Pathophysiology
Airway is abnormally reactive - heightened sensitivity
N ot es
Q U E S T I O N S

Trigger causes a response

Inflammation and excess mucus production occur

D E T A I L S

Bronchospasm decreases the airway diameter

Airflow becomes obstructed

After many asthma reactions, airway remodeling occurs which causes scarring
and changes to lung tissue

Assessment
Shortness of breath
Unable to speak
Evaluate how many words they
can say before taking a breath
Cough
Increased work of breathing Wheeze S U M M A R Y
Retractions Prolonged expiration
Tracheal tug Can’t hear any breath sounds?
Head bobbing Complete obstruction!

Albuterol
Therapeutic class: Bronchodilator; short-acting beta 2 agonist (SABA)
Indications: Asthma, COPD
Action: Binds to beta-2 adrenergic receptors in the airway leading to relaxation
of the smooth muscles in the airways
Nursing Considerations:
Be very cautious when using in clients with heart disease, diabetes,
glaucoma, or seizures
Causes tachycardia

Terbutaline
Therapeutic class: Selective beta 2 adrenergic agonist K E Y T E R M S
Indications: Rescue/relief and maintenance drug for wheezing, SOB, and
coughing caused by asthma
Action: Binds to beta 2 adrenergic receptors in the respiratory system to cause
bronchodilation by inhibiting the release of hypersensitivity reaction products
from mast cells
Nursing Considerations:
Side effects: jitteriness, dizziness, drowsiness, sleep disturbances,
weakness, headache, nausea, vomiting, tachycardia, hypertension,
hyperglycemia, CNS overstimulation
Assess HR, BP, EKG, blood glucose
Can be given orally, SC, or by inhaler
4-6 hour duration
More side effects with oral administration because it requires higher
dosage
Teach proper inhaler use
44
 Archer Review

Let’s reassess: N ot es
Q U E S T I O N S

D E T A I L S

AGE 14

5' 2'' 112 lbs RA

Treatment - Acute Exacerbation

S U M M A R Y
Airway, Breathing, Circulation!

Airway
Intubate?
Adrenergic agonists
Open up airway
Albuterol

Breathing
Oxygen administration
Theophylline -
Bronchodilator
Dexamethasone -
Steroid - reduce
inflammation

Circulation
IV fluids

K E Y T E R M S

45
 Archer Review

Non-Invasive Ventilation
N ot es
Q U E S T I O N S

D E T A I L S

Asthma Complication
Status Asthmaticus

Asthma attack that is

refractory to treatment
S U M M A R Y
Leads to severe
respiratory failure
Can progress to death if
untreated

We put James on HFNC, started continuous albuterol, and administered

dexamethasone. Now his asthma attack is under control. Great job!
Time to talk about long term treatment so this doesn’t happen again….

Treatment - Long-term control

Inhaled Budesonide & fluticasone
Inhaled Corticosteroids
Corticosteroids Take daily
Budesonide & Fluticasone
Take daily Montelukast sodium
Leukotriene
Leukotriene modifiers Blocks leukotrienes from over responding to
Modifiers
Montelukast sodium triggers
Blocks leukotrienes from over responding to triggers K E Y T E R M S

Theophylline Bronchodilator
Theophylline
Bronchodilator Helps keep bronchioles open and prevent
wheezing,
Helps keep bronchioles open and butbut
prevent wheezing, must beused
must be used regularly
regularly

Allergen control
Clean environment
Clean environment
Allergen Control Minimize dust, pet dander, and mold
Minimize dust, pet dander, and mold
No secondhand smoke No secondhand smoke

Steroids
Betamethasone
Dexamethasone
Cortisone
Methylprednisolone 46
 Archer Review

Methylprednisolone
Therapeutic class: corticosteroid N ot es
Indications: Inflammation, allergy, autoimmune disorders Q U E S T I O N S
Action: Suppress inflammation and normal immune response
Nursing Considerations:
Monitor for too much steroids
Cushing’s symptoms - buffalo hump
Side effects
Immunosuppression
D E T A I L S
Hyperglycemia
Osteoporosis
Delayed wound healing

Antihistamines
Type Action Example

Histamine-1 Block H1 receptors in CNS

Diphenhydramine
blocker - stops allergies

Histamine-2 Famotidine
Block production of stomach acid
blocker Ranitidine S U M M A R Y

Diphenhydramine
Therapeutic class: Antihistamine
Indications: Allergy, anaphylaxis, sedation
Action: Antagonizes effects of histamine, CNS depression
Nursing Considerations:
Monitor for drowsiness
Anticholinergic effects

NGN Practice Question

The 12-year-old child with a history of asthma is brought to urgent care.

Nurses’ Notes
1700 – 12-year-old male arrives with his parents after playing outside with K E Y T E R M S
friends and suddenly developing shortness of breath. The client’s mother
believes he is having an asthma attack. He has a medical history of asthma,
insulin dependent diabetes mellitus, and is current on all immunizations. No
known allergies.

Vital signs Assessment

Temp 99 ᵒ F (37.2ᵒ C) Client is alert and fully oriented. Anxious and unable
to respond in full sentences. Appears in significant
Pulse 114 bpm distress. Peripheral pulses were palpable. Skin was
RR 26 bpm cool and dry to touch. Respirations were labored with
audible wheezes and expiratory stridor. Tachypnea
BP 107/76 mm Hg and use of accessory muscles. Frequent, non-
productive cough. Active bowel sounds in all
SpO2 89% quadrants. Client reported no pain.
47
 Archer Review

Question
The nurse reviews the assessment information and identifies that which two (2)
pieces of assessment data require follow-up?
N ot es
Q U E S T I O N S
a. The client being anxious
b. Non-productive cough
c. Audible expiratory stridor
d. History of diabetes mellitus
e. Temperature of 99 ᵒ F (37.2ᵒ C)
f. Oxygen saturation of 89% D E T A I L S

NGN Answer:
A cough and the client being anxious are common findings associated with asthma.
The most concerning finding that requires follow-up is the audible stridor and the
oxygen saturation of 89%. Stridor signifies that the upper airways are closing,
which indicates that the asthma attack is advancing. The low oxygen saturation
further supports the seriousness of this asthma attack.

Chronic Obstructive
Pulmonary Disease (COPD)
What is COPD? S U M M A R Y

A group of lung
diseases that block
airflow and make it
difficult to breathe

Includes:
Emphysema
Chronic
bronchitis
Damage is not
reversible

K E Y T E R M S

48
 Archer Review

Assessment
Barrel chest
Notes
Q U E S T I O N S
Accessory muscle use
Retractions
Nasal flaring
Tracheal tug
Congestion
Lung sounds
D E T A I L S
Diminished
Crackles Normal Chest Barrel Chest
Wheezes Anterior to posterior Anterior to posterior
Acidotic diameter is short to the diameter is EQUAL
Hypercarbic transverse diameter. to the transverse
Hypoxic diameter.

Treatment
Be very careful with oxygen administration!
In the normal client, hypercarbia stimulates the body to breathe
This client has been hypercarbic for an extended period of time
For them, hypoxia has become the driving factor to stimulate
breathing
Bronchodilators
Chest physiotherapy
Increased fluid intake S U M M A R Y
Encourage pursed lip breathing to help expire completely
Eat small frequent meals to avoid overdistention of the stomach which
impedes the diaphragm

Simple face mask Non-rebreather Nasal Cannula

K E Y T E R M S
The HCP has already
A year later, you ordered a CXR:
move to a new job
at the urgent care
and one night who
comes in but your
old friend James!
Let’s see what he
came in for...

49
 Archer Review

Pneumonia N ot es
Q U E S T I O N S
What is Pneumonia?
Inflammation of the lung affecting the
alveoli
Alveoli
Tiny air sacs of the lungs which D E T A I L S
allow for gas exchange
Alveoli become filled with pus and
liquid
This blocks gas exchange from
occurring

Classifications
Viral
Caused by viruses such as RSV,
adenovirus, and influenza
Bacterial
Fungal
Chemical irritation
Aspiration
When foreign bodies such as food and
secretions enter the lungs S U M M A R Y
Causes inflammation and infection
leading to pneumonia

Diagnosis

Chest X-Ray
“Patchy infiltrates”

Sputum culture
Bacterial source detected

K E Y T E R M S
Assessment
High fever
Cough
Tachypnea
Crackles
Chest pain
Work of breathing
Retractions
Tracheal tug
Nasal flaring
Head bobbing
Accessory muscle use
Pursed lip breathing

50
 Archer Review

Treatment In addition: N ot es
Maintain airway Chest physiotherapy Q U E S T I O N S
Suction Antipyretics
Monitor SpO₂ Analgesics
Monitor breathing Cough suppressant
Assess for increased work of Expectorants
breathing Antibiotics if bacterial source D E T A I L S
Provide support as needed Isolation (dependent on type)
Humidified oxygen
Maintain circulation
Monitor for dehydration
IVF if unable to tolerate PO

Misc. Respiratory Medications

Montelukast Leukotriene modifier

Guaifenesin Expectorant

S U M M A R Y
Acetylcysteine Mucolytic

Pseudoephedrine, phenylephrine Decongestant

Dextromethorphan, codeine Antitussive

Acute Respiratory
Distress Syndrome (ARDS)
“An acute condition characterized by bilateral pulmonary infiltrates and severe
hypoxemia in the absence of evidence for cardiogenic pulmonary edema”

K E Y T E R M S
Fluid collects Deprives body
in alveoli of oxygen

Normal alveoli Alveoli in ARDS

51
 Archer Review

Notes
Q U E S T I O N S

D E T A I L S

What acid-base imbalance do we see in ARDS?

Causes Anything that causes an inflammatory S U M M A R Y

Sepsis reaction in the lungs!

Trauma

Burns

Aspiration

Overdose

Near drowning

Assessment
Chest x-ray
Diffuse bilateral infiltrates
“Whited-out”
Hypoxemia
Pale K E Y T E R M S
Cool
Dusky
Mottled
Low SpO2

Treatment
Intubation and mechanical ventilation
High pressures Treat the
Prone positioning underlying
Prevent infection condition!
Prevent barotrauma

52
 Archer Review

The MD
determines
N ot es
Q U E S T I O N S
James’ airway is
in danger.
What do you
anticipate?
D E T A I L S

Endotracheal Tube (ETT)

Invasive, artificial airway used when the client is

unable to protect their own airway

Plastic tube inserted into the

trachea through the mouth or nose
Maintains an airway to deliver
oxygen and positive pressure to
the lungs
“Breathing tube”
S U M M A R Y

Nursing Must Know

After placement of an ETT, placement should be verified by chest x-ray
Assess for equal breath sounds and chest rise bilaterally
The ETT can become displaced into the right main stem bronchus
Ensure that breath sounds are heard equally bilaterally or the tube
may need to be repositioned

Tracheostomy
An artificial airway used for long-term needs
Stoma is made in the neck and the tube is inserted into the trachea
Breathing occurs through the tracheostomy, not the nose and mouth

Used for:
Tracheal obstruction K E Y T E R M S
Slow ventilator weaning
Tracheal damage
Neuromuscular damage
Cannot place ETT tube/client
decompensates

Dressing
and Ties

53
 Archer Review

Tracheostomy care
N ot es
Position client into fowler’s or semi-fowler’s Q U E S T I O N S

Don PPE and prepare site

Perform hand hygiene and don clean gloves
Remove soiled dressing
D E T A I L S
Perform hand hygiene again and don sterile gloves

Clean the tracheostomy site

Use sterile applicators or gauze dressings moistened with NS
1:1 NS and hydrogen peroxide is used with some clients
Use each applicator/gauze once, then discard
Dry client’s skin

Apply new sterile dressing

Change tracheostomy ties

Check tightness - ensure 1 finger can fit underneath

Infection prevention is key!

S U M M A R Y
The natural defenses of the nose and
mouth are bypassed
Higher risk for infection
Daily trach care in inpatient setting
This is a sterile procedure

Suctioning & Safety

Only suction to the pre-measured depth
Suctioning too deep can cause damage or
Suctioning laryngospasm
Don’t suction longer than 10 seconds
Some clients may need pre-oxygenation with 100% FiO2

Keep two backup tracheostomy tubes at the bedside in

case of emergency
1 of the same size
Safety 1 a half size smaller K E Y T E R M S
If the trach comes out, first try to insert the backup of the
same size
If unsuccessful, try to insert the half-size smaller

Invasive Ventilation
Endotracheal tube
Tracheostomy
Mechanical ventilator

54
 Archer Review

Ventilator Alarms N ot es
Q U E S T I O N S

D E T A I L S

Knowledge Check!

Copious
Name the
Tubing
secretions ventilator alarm! disconnect S U M M A R Y

Treatment
Intubation and mechanical ventilation
High pressures

Prone positioning

Prevent infection
Ventilator associated pneumonia
TREAT THE
UNDERLYING
Prevent barotrauma CONDITION!

K E Y T E R M S

Pneumothorax

AIR IN THE Space between the lung and the chest wall
OR PLEURAL Normally contains a small amount of fluid
SPACE Helps the lungs glide smoothly during
GAS
breathing
When air enters it causes the lung to collapse

55
 Archer Review

TWO TYPES

Spontaneous
N ot es
No apparent cause, often due to the rupture of small air Q U E S T I O N S
sacs (alveoli) in the lung
Commonly seen in those with lung diseases like COPD

Traumatic D E T A I L S
Caused by chest injuries such as rib fractures, puncture
wounds, or medical procedures that accidentally
puncture the lung, like central line insertions or
mechanical ventilation

Assessment
Decreased or absent breath sounds on the affected side
Asymmetrical chest wall movement on the affected side
Sudden, sharp, and localized chest pain on the affected side
Dyspnea
Rapid, shallow breathing
Tachypnea
Cyanosis
Tension pneumothorax may present with severe respiratory distress, tracheal
deviation away from the affected side, and hemodynamic instability S U M M A R Y

Treatment
Chest tube

Deep breathing
Semi-Fowler’s position

Pain management
Oxygen

Chest Tubes
K E Y T E R M S

What is a Chest Tube?

Tube inserted into the pleural space of the lungs
Helps to remove air or fluid that has caused the lung to collapse
Also placed after cardiac surgery to help drain blood and fluid
from around the heart

56
 Archer Review

Chest Tube Indications N ot es

Q U E S T I O N S
Why would our client need a chest tube?

There is something in the pleural

space….and we need to get it out!
D E T A I L S
Air
Fluid
Blood

This allows the lung to fully expand

Drainage System Chambers

S U M M A R Y

Nursing Considerations
Always keep the drainage system below the level of
K E Y T E R M S
the client's chest
Ensure the tubing is free of kinks and draining freely
There should be no dependent loops in the tubing
Know WHY the client has a chest tube!
Monitor the drainage
Color - serous or serosanguinous
Odor - none
Consistency - thin-thick
Amount - no more than 70ml/hr
More? Or drainage stops in the first 24
hours? Notify the HCP!
Mark hourly

57
 Archer Review

What to do if the chest tube comes out

Cover the site with a sterile dressing
N ot es
Tape on 3 sides Q U E S T I O N S
Air can escape this way. If you tape
on 4 sides you might cause a tension
pneumothorax
Call the primary healthcare provider
STAY WITH THE CLIENT
D E T A I L S
Tape on three sides!

What to do if the tube

disconnects from the
drainage collection system?
Chest tube is still in the client,
Place end of tube in
but becomes disconnected from
the collection chamber sterile water!
Place the end of the chest tube
in a bottle of sterile water

Pulmonary Embolism S U M M A R Y

What is a Pulmonary Embolism?

Life threatening blood clot in the lungs
Can be caused by an embolism from a vein
entering the lung, or a clot during surgery
The clot decreases perfusion causing
hypoxemia
Can lead to right heart failure if untreated

Treatment
Oxygen

High Fowler’s position K E Y T E R M S

Promotes maximum lung expansion
and assists with breathing

Anticoagulants

Assessment Thrombolytics
Anxiety
Dyspnea
Chest pain What position do you use
Hypoxemia
Rales for a pulmonary
Diaphoresis embolism?
Hemoptysis
58
 Archer Review

Positioning for Air Embolism vs.

N ot es
Pulmonary Embolism Q U E S T I O N S

D E T A I L S

Keeps the
blot clot in
the right
atrium so that
it doesn’t go
to the lungs

S U M M A R Y

Allows for
better lung
expansion to
improve
breathing

K E Y T E R M S

You finished respiratory!

Great work!

59
ANSWER KEY - RESPIRATORY
Page 42 Ventilation
Page 43 breath Chronic inflammation
Page 44 Unable to speak tachycardia 4-6 hour duration
Page 45 Airway Oxygen IV Fluids
Page 46 Constant set pressure Two
Page 47 Buffalo hump Diphenhydramine
Page 48 C and F reversible
Page 49 Barrel chest oxygen administration!
Page 50 Alveoli Aspiration Pursed lip breathing
Page 51 Maintain airway hypoxemia
Respiratory acidosis “Whited-out”
Page 52 Prone positioning
Page 53 Mouth or nose bilaterally
Page 54 1 finger sterile procedure 10 seconds
Page 55 High Low High Low barotrauma
Page 56 Spontaneous affected side Chest tube
Page 57 Water seal chamber Tidaling 70 mL/hr
Page 58 Stay with the client Hemoptysis High fowler’s position

60
 Archer Review

Notes
Q U E S T I O N S
PRIORITIZATION
W H A T O R W H O
N E E D S I M M E D I A T E D E T A I L S

A T T E N T I O N ?

S U M M A R Y

ABCs of Prioritization
K E Y T E R M S

61
 Archer Review

Spectrum of Stability
Transfer to ICU N ot es
Acute
Q U E S T I O N S
Unexpected Prepare for discharge
Assess first Assign for float RN
Changing condition Assign to new grad RN

Middle of
Unstable Less stable More stable Stable
the road D E T A I L S

Recently admitted Expected findings

New-onset Chronic conditions
Newly diagnosed Consistent lab values
Unchanging

NCLEX Question
You are called to assess a 4-year-old client who has suffered second and
third-degree burns to her chest, abdomen, and legs. It is estimated that
about 40% of her TBSA is burned. Upon assessment, her vital signs are as
follows:
HR: 140 RR: 44 BP: 90/60 SpO2: 88% on room air
Which of the following interventions is the priority?
A. Fluid replacement
B. Intubation and mechanical ventilation
S U M M A R Y
C. Wound debridement
D. Standard precautions

Answer: B
Choice B is correct. Intubation and mechanical ventilation are the priority for this
client. Intubation is the "A" in the ABC’s mnemonic and stands for airway. The
stem of the question states that this client has burns to her chest. You know that
smoke inhalation can burn the trachea and compromise the airway, and wounds to
the chest are an indication that inhalation injury has likely occurred. Additionally,
the client is tachycardic, tachypneic, and desaturated. She is working hard to
compensate by increasing her heart and respiratory rates. Still, it is not keeping up
with her oxygenation and perfusion needs, as evidenced by the client's
desaturation in room air. This client needs intubation and mechanical ventilation
immediately to secure the airway and prevent rapid respiratory failure due to
inhalation injury. Remember your ABCs! Airway, Breathing, Circulation. This is the
correct order of priority actions! You must address the airway first!
Choice A is incorrect. Although fluid replacement will be necessary when treating
a burn victim, it is not the priority action and is the incorrect answer to this K E Y T E R M S

question. Every answer here is a correct action that would be necessary during the
care of your client, but the priority is not a fluid replacement. If you picked this
answer, you might remember that a large amount of third spacing occurs during
the first 24 hours after a burn. Hypovolemic shock can ensue if adequate fluid
replacement does not occur. This falls under the "C" in your ABCs, which stands
for circulation. While fluid replacement is essential, you must prioritize the airway.
Choice C is incorrect. While wound debridement is undoubtedly essential for
infection prevention and healing in the burn victim, there is a more urgent priority.
Wound debridement is not part of your ABCs or an immediate priority.
Choice D is incorrect. Although it is correct to implement standard precautions for
a burn victim to prevent infection, a more urgent priority is present. Implementing
standard precautions is not a part of the ABCs and is not an immediate priority for
this client.
62
 Archer Review

Maslow’s Hierarchy of Needs

N ot es
Q U E S T I O N S

D E T A I L S

The Nursing Process

S U M M A R Y

NCLEX Question
The nurse is taking vital signs on her client with a diagnosis of acute lymphocytic
leukemia. Their temperature is 38.7C (101.6F). What is the nurse's first priority?
A. Place cool washcloths on the client’s head.
B. Continue with her assessment.
C. Obtain intravenous access on the client.
D. Assess the client’s perfusion

Answer: C
C is correct. The priority action is to establish intravenous access for this client.
This client has a diagnosis of ALL, so the nurse knows that he is
immunocompromised. He is very susceptible to infections, and with a fever of 38.7
C, the nurse should have a great deal of suspicion that the client has some sort of K E Y T E R M S
infection. Broad-spectrum IV antibiotics will need to be initiated right away.
Therefore, the priority for the nurse is to start an IV.
A is incorrect. Placing cool washcloths on the client's head is not the priority, as
there is a better answer. This would only need to be done if the client was at risk
for seizures due to an incredibly high body temperature. The temperature of 38.7C
does not warrant cooling measures, and the nurse has another immediate priority,
given the client's immunosuppression and her suspicion of an infection.
B is incorrect. It is not appropriate for the nurse to continue with her assessment.
She suspects an infection in her immunocompromised client. Another answer has
an immediate priority.
D is incorrect. Assessing the client's perfusion has nothing to do with the nurse's
suspicion that the client likely has an infection. She should immediately establish
IV access for the administration of antibiotics

63
 Archer Review

N ot es
Q U E S T I O N S

Priority
toolkit D E T A I L S

S U M M A R Y

Priority toolkit

ABCs
1
Who is the most unstable?
2
Maslow’s hierarchy of needs
3
Nursing process
4
K E Y T E R M S

Pain doesn’t kill your client.

Anxiety doesn’t kill your client.

Only call the HCP if there’s nothing you can do to help your client

Least invasive > Most invasive

64
 Archer Review

Notes
Q U E S T I O N S

TEST ANXIETY
H O W T O C A L M
D E T A I L S
Y O U R N E R V O U S
S Y S T E M

Testing Anxiety - What is it?

S U M M A R Y

Prevention

K E Y T E R M S

Combating
Test Anxiety

65
 Archer Review

Combating Test Anxiety

N ot es
Q U E S T I O N S

D E T A I L S

The 3-2-1
Rule for
Anxiety
S U M M A R Y

ANSWER KEY -
PRIORITIZATION/TESTING
STRATEGIES
Page 61 Intubate Adequate respirations Fluids

Page 62 B

Page 63 C

K E Y T E R M S

Day 1,
done!
See you tomorrow
morning at 9:00 am
Central Time!
66
 Archer Review

N ot es
Q U E S T I O N S

D E T A I L S

DAY 2 SCHEDULE
9 AM - 4 PM CT

S U M M A R Y

K E Y T E R M S

68
 N ot es
Q U E S T I O N S

D E T A I L S

Anatomy + Physiology Neurovascular Disorders

CNS & PNS Skull injury
Meninges Hydrocephalus
Cerebrospinal fluid Meningitis
Intracranial pressure SCI
GCS scoring Stroke
Neuro Pharmacology Seizures

S U M M A R Y

Case #1: Jayne Headachin

Mrs. Jayne is a professional hockey player and
supermom to 4 kids. She was outside playing on roller
skates with her 6 year old when he threw a hockey puck
at her head. She briefly passed out, woke back up, and
her husband had called 911.

Let’s look at some of the anatomy in her noggin before

EMS arrives….

Central vs. Peripheral Nervous System

K E Y T E R M S

69
 Archer Review

Nervous System Breakdown N ot es

Q U E S T I O N S

D E T A I L S

Meninges
Three layers of connective
tissue covering the CNS

S U M M A R Y

All right, time’s up! EMS has

arrived at Mrs. Jayne’s house!

User:Rvervuurt (original photo) / WikiFB3

(crop), Black eye 2, CC BY-SA 3.0

K E Y T E R M S
Pupils are PERRLA Current GCS is 14 Significant periorbital
bruising where the
Pupils are equal, round, reactive Minus one for confusion hockey puck hit her in
to light and accommodation (but remember, she was passed
the left eye
out a few minutes ago!)
Additional bruise forming over
the R mastoid process

What do you suspect EMS is worried

about?

70
 Archer Review

Skull Fracture
N ot es
Open fracture Torn dura
Q U E S T I O N S
Closed fracture Dura is intact
Basilar skull fracture
Battle’s sign Bruising over the
mastoid process
Raccoon eyes Periorbital bruising
Cerebrospinal rhinorrhea
D E T A I L S
Test drainage for CSF
Halo test
Glucose

Never insert an NG
tube in a client with a
suspected basilar
skull fracture!

S U M M A R Y

Do you suspect
an epidural or
subdural
hematoma?

Mrs. Jayne has an obvious basilar

K E Y T E R M S
skull fracture. Her expert EMS crew
keeps EVERYTHING OUT OF HER
NOSE and gets her to the hospital.
Based on her presentation of
passing out and waking back up,
they are in a hurry... they think Mrs.
Jayne's brain is bleeding.
71
 Archer Review

Intracranial Hemorrhage N ot es
Q U E S T I O N S

D E T A I L S

Superior
sagittal sinus

Mrs. Jayne's GCS upon arrival

S U M M A R Y
to the hospital...

K E Y T E R M S

What intervention would you prepare for

with an epidural hematoma?

72
 Burr hole drilled...but that's not N ot es
everything building up in Mrs. Jayne's Q U E S T I O N S

skull. What else is in there?

D E T A I L S
Cerebrospinal Fluid
Brain Cerebrospinal
fluid

A clear, odorless liquid found in Fluid

your brain and spinal cord

Spinal
cord

Intracranial Pressure (ICP)

The pressure inside of the skull Monro-Kellie Hypothesis S U M M A R Y
Normal = 5-15
Causes of increased ICP The skull is a rigid container filled
Tumor with: blood, brain, and CSF. If
Bleeding
Hydrocephalus [ increases,
one of those three
another must decrease.
Edema

Symptoms of Elevated ICP

K E Y T E R M S

Mrs. Jayne has blood and CSF

building up inside the rigid
compartment of her skull. Intracranial
pressure is going up! This can lead to...
73
 Archer Review

Hydrocephalus N ot es
Q U E S T I O N S
Increased accumulation of cerebrospinal fluid
Increases ICP

Causes:
D E T A I L S
Tumor
Hemorrhage
Infection
Congenital

EVD v.s. VP Shunt

External Ventricular Drain (EVD)

Can also be
S U M M A R Y
used to
measure ICP

Ventriculoperitoneal (VP) Shunt

Ventricle: Space in the brain
Peritoneum: Serous membrane lining the
abdominal compartment
Shunt that drains extra CSF from brain to
the abdomen, where it can then be
excreted as urine

K E Y T E R M S

An EVD is emergently placed

right after the burr hole procedure
to drain the extra CSF from Mrs.
Jayne's brain.
The pressure in her brain stabilizes.
She is transferred to the ICU.
74
 Archer Review

Two days later, you go to the N ot es

unit to check in on Mrs. Q U E S T I O N S

Jayne.
Let's see how she's doing. D E T A I L S

S U M M A R Y

What vital signs are you concerned with?

Her provider rounded and told

you that they're concerned and
ordered labs. A lumbar puncture was
also performed. The results just came
back. Here they are:
K E Y T E R M S

Cerebrospinal Fluid WBC 25,000 mm3

5,000-10,000
mm3

Glucose 25 mg/dL 50-75 mg/dL

Neutrophils 80% 55-70%

Protein 175 mg/dL 20-40 mg/dL

Lymphocytes 15% 20-40%
Opening
270 cm H2O <20 cm H20 C-Reactive
Pressure 120 mg/mL < 1.0 mg/dL
Protein

The spinal fluid appears cloudy

75
 Archer Review

Oh no! If Mrs. Jayne got an N ot es

infection from her EVD, Q U E S T I O N S

she might have...

Meningitis D E T A I L S

What is Meningitis?

Inflammation of the spinal cord or brain

Usually caused by a virus or bacteria
Rarely caused by fungi or parasites

Bacterial meningitis is more

dangerous compared to viral

S U M M A R Y

Bacterial meningitis

K E Y T E R M S

76
 Archer Review

Assessment N ot es
Q U E S T I O N S
Nuchal rigidity
Photophobia
Kernig’s sign
Brudzinski’s sign
Brudzinski’s Sign
D E T A I L S
With the client placed supine, passive flexion
of the neck causes involuntary flexion of the
knee and hips.

Kernig’s Sign

With the client placed supine and the hip

flexed, the knee cannot be completely
extended due to pain. S U M M A R Y

K E Y T E R M S

77
 Archer Review

Treatment
Steroids
Notes
Analgesics Q U E S T I O N S
Antibiotics - only if bacterial!!
Isolation precautions
Viral - standard
Bacterial - Droplet
Considered a medical emergency
Bacterial meningitis is VERY contagious D E T A I L S
Prevention
Hib vaccine
Those who are immunized have protection against Hib
meningitis
Meningococcal conjugate or MenACWY vaccines
Recommended for anyone living in close proximity to others

Her fever is up to 40.3℃ (104.5℉)

and her ICP is still rising.
Mrs. Jayne is at risk for one of our
scariest neuro complications...
S U M M A R Y

Seizures

What are Seizures?

Seizures are not a disease in
themselves, but a symptom of an
underlying disorder

Increased ICP
Infection in the brain
Injury to the brain K E Y T E R M S
Drug abuse
Hyper- or hypoglycemia
Hyponatremia
Medications

Epilepsy “A neurological disorder marked by sudden recurrent

episodes of sensory disturbance, loss of consciousness,
or convulsions, associated with abnormal electrical
activity in the brain.”
No other underlying disorder

78
 Archer Review

Types of Seizures
Notes
Tonic-clonic: phases of tonic (muscle stiffening/rigidity) and clonic
Q U E S T I O N S
(rhythmic jerking) spasm, immediate loss of consciousness
Generalized
involve both cerebral
Myoclonic: sudden, brief, shock-like contractions of a muscle/group
hemispheres
of muscles in extremities

Atonic: abrupt loss of muscle tone for a few seconds, then confusion
(can result in falls/injury)
D E T A I L S
Absence: loss of consciousness, staring off into space

Partial (Focal) Complex: impaired consciousness ranging from confusion to syncope

begin in a part of and/or non-responsiveness
one hemisphere

Simple: no loss of consciousness, may experience twitching, sensory

changes, or autonomic symptoms

Seizure Precautions

S U M M A R Y

Dos and Don’ts During a Seizure

K E Y T E R M S

Do or Don’t? Do or Don’t?
Insert a bite Stay with
block the client

79
 Archer Review

Treatment Notes
Anticonvulsants Q U E S T I O N S
Rapid acting - lorazepam
Long acting - phenytoin
Very important to monitor for therapeutic levels
Never stop taking suddenly (can cause a seizure)

D E T A I L S
Antianxiety Agents: Benzodiazepines
Onset: rapid
Short-Acting Midazolam Duration: 1-2 hours
Quick on / quick off

Onset: intermediate
Alprazolam Duration: 6-12 hours

Intermediate- Onset: intermediate

Clonazepam Duration: 18-50 hours
Acting
Onset: rapid IV, intermediate PO
Lorazepam Duration: 2-6 hours
Medium on / long off

Onset: rapid
Long-Acting Diazepam Duration: 20-50 hours
Quick on / long off

Anticonvulsants S U M M A R Y

Phenytoin
Gabapentin
Levetiracetam

Phenytoin
Therapeutic class: Anticonvulsant
Indication: Seizures
Action: Blocks sustained high-frequency repetitive firing of action potentials
Nursing Considerations:
Therapeutic level: 10-20 mcg/mL
Side effect: gingival hyperplasia
Regular dental check-ups
Use soft bristle toothbrush
Antacids can reduce the effect of phenytoin and should be avoided

NCLEX Question K E Y T E R M S

Seizure precautions have been ordered for a client admitted to the med-surg unit.
Which of the following nursing interventions is not appropriate when initiating
seizure precautions? Select all that apply.

a. Pad the side rails of the bed

b. Lower side rails while the client sleeps
c. Remove hard or sharp objects from the bed
d. Use four-point restraints to prevent injury
e. Affix a fall risk bracelet to the seizure-prone client
f. Ask the family to monitor the client 24/7

80
 Archer Review

Answer: B, D, + F
The correct answers are B, D, and F. Padded bed rails should remain up while the
N ot es
client sleeps. Clients should be provided with a call light so that they may call for Q U E S T I O N S
help if needed. Four-point restraints are not appropriate for the seizing client and
could result in injury. It is not appropriate to ask the family to monitor the client
24/7.
Choice A is incorrect. When initiating seizure precautions, the nurse should ensure
that the side rails are padded.
Choice C is incorrect. All sharp objects should be removed from a client's bed D E T A I L S
when instituting seizure precautions.
Choice E is incorrect. Clients prone to seizures should wear a fall risk bracelet to
alert members of the health care team to the client's need for increased supervision.

You did it! You are a safe nurse

that knows your seizure precautions
and protected Mrs. Jayne in her time
of need.
She makes a full recovery and is S U M M A R Y

back to playing hockey with her kids

in no time.

Spinal Cord Injury

What is a Spinal
Cord Injury?

Damage to the spinal cord causes K E Y T E R M S

permanent changes in strength,
sensation and other body functions
below the site of the injury
Symptoms depend on the location
of the injury
The higher the injury, the more
function that is lost
Injuries at and above T6:
Monitor for autonomic
dysreflexia

81
 Archer Review

Autonomic Nervous System

N ot es
Q U E S T I O N S

D E T A I L S

S U M M A R Y

Autonomic Dysreflexia
Syndrome characterized by:
Sudden severe hypertension
Bradycardia
Headache
Nasal stuffiness
Can occur in
Flushing
spinal cord
Sweating
injuries at or
Blurred vision
above T6
Anxiety

K E Y T E R M S

Success in nursing isn't just about

knowing the right answers—it's about
the determination to keep going until you
find them. You're closer than you think!

82
 Archer Review

Autonomic Dysreflexia
N ot es
Q U E S T I O N S

D E T A I L S

S U M M A R Y

Autonomic Dysreflexia Triggers

K E Y T E R M S

Treatment
Sit the client up to lower their BP
Antihypertensives
Hydralazine
Find the cause and treat
Full bladder? Catheterize
Constipated? Remove impaction
Pressure injury? Reposition
Painful stimuli? Remove stimuli
Cold room? Adjust temperature
83
 Archer Review

Stroke N ot es
(Cerebrovascular Accident) Q U E S T I O N S

What is a Stroke?
D E T A I L S
A condition impacting the blood vessels supplying the
brain, this ailment stands as a major contributor to
mortality and impairment in the United States. A
stroke transpires when a blood vessel responsible for
transporting oxygen and nutrients to the brain is
obstructed by a clot or ruptures.

There is a lack of oxygen to

the brain, and that causes
damage!

A stroke can be:

Hemorrhagic
Ischemic
Embolic
Thrombotic
S U M M A R Y
Hemorrhagic Ischemic

Pathophysiology - Hemorrhagic Stroke

A vessel ruptures and bleeds into the brain
Worst As the blood accumulates, there is
headache of increased pressure on the brain
my life! The rupture can be caused by a weakened
vessel, such as an aneurysm

Pathophysiology - Ischemic Stroke

Blood flow to the brain is blocked by a blood
K E Y T E R M S
clot
Thrombotic - a blood clot (thrombus) in
an artery going to the brain
Onset in a stepwise fashion
Embolic - a clot that has formed
elsewhere (usually in the heart or neck
arteries) travels in the bloodstream and
clogs a blood vessel in or leading to the
brain
Sudden onset!
There is a loss of blood circulating to this area
of the brain
The lack of blood flow leads to a lack of
oxygen, causing ischemia and damage

84
 Archer Review

Assessment N ot es
Q U E S T I O N S
Stroke warning signs -
We need to BEFAST!

D E T A I L S

Balance
Dizziness leading to a loss
of balance S U M M A R Y
Eyes
Blurry vision
Abnormal pupil response
Hemianopia
Facial droop
Unilateral
Arms
Arm drift or weakness
Speech
Aphasia Strokes can cause unilateral facial
Dysphagia paralysis, resulting in speech and
Altered LOC/Confusion swallowing issues!

Treatment

Ischemic Hemorrhagic
K E Y T E R M S

Permissive hypertension Get the bleeding under control

Ensure there is perfusion to the brain
Antithrombotics If caused by an aneurysm:
tPA: break up clot to restore blood flow
Must be administered within 3-4.5 Coiling - interventional radiology
hours of onset of symptoms
Clipping - surgical procedure
Door-to-tPA = 45 minutes or less
Percutaneous thrombectomy Craniotomy
Surgical removal of clot
Done in interventional radiology External ventricular drain (EVD)

85
 Archer Review

Willie's NGN Practice Question

Willie arrives at the emergency department.
N ot es
History and Physical Vital Signs Q U E S T I O N S

1900: The client arrives with left Temperature 99.5° F (37.5° C)

facial droop, inability to move his
left arm and leg, and expressive Pulse 86
aphasia. The symptoms started 45-
minutes prior to arrival at the ED. Respirations 18 D E T A I L S
Past medical history includes SCI to
Blood Pressure 181/109 mmHg
T4, hypertension, diabetes mellitus,
and hyperlipidemia.
Oxygen Saturation 95% on room air

Complete the diagram by dragging

from the choices below to specify
what condition the client is most
likely experiencing, two (2) actions
the nurse should take to address that
condition, and two (2) parameters the
nurse should monitor to assess the
client’s progress.

S U M M A R Y

Willie's NGN Answer

K E Y T E R M S

What is your
priority action for You finished neuro!
autonomic Keep up the great work!
dysreflexia?

86
 ANSWER KEY -
NEUROLOGICAL SYSTEM
Brain and spinal cord
Page 70
Cranial and spinal nerves
Page 71 Raccoon eyes
Page 73 5 - 15
Page 74 Increases ICP
Page 77 Kernig’s sign
Standard
Droplet
Page 78
Hib vaccine
Epilepsy
Leave the client
side-lying
Page 79
Don’t!
Do!
lorazepam
Page 80
10 - 20 mcg/mL
B, D, and F
Page 81
T6
Page 82 Sudden severe hypertension
Ischemic
Page 84
Blood clot
tPA
Page 85
bleeding
Page 86 Sit the client up

87
 Archer Review

N ot es
Q U E S T I O N S

D E T A I L S

Anatomy + Physiology
GI Disorders + Pharmacology (Case Study)
Ulcers
Pancreatitis
Ulcerative Colitis
Hepatitis
Crohn's
Cirrhosis
Appendicitis
S U M M A R Y

Digestive Tract Accessory Organs

Mouth Pancreas
Esophagus Liver
Stomach Gallbladder
Pyloric sphincter
Small intestine
Duodenum
Jejunum
Ileum
Large intestine (colon)
Rectum
Anus

Digestive Tract
K E Y T E R M S

Esophagus

88
 Archer Review

Stomach N ot es
Temporary storage for food Q U E S T I O N S
Mixing and breakdown of food
Acidic environment
pH of stomach acid - 1.5 to 3.5 - (rises
when food enters) Esophagus

Pyloric sphincter D E T A I L S
Closes to keep food in the stomach
Opens to send food into the small intestine

S U M M A R Y

Small Intestine
Receive digesting enzymes from the
pancreas and liver (via the pancreatic
and common bile ducts)
Churn and mix ingested food, making it
into chyme Esophagus
Absorb nutrients!!
Move the food along its entire length
(into the colon)

K E Y T E R M S

89
 Archer Review

Large Intestine (aka the Colon)

Absorbs water and electrolytes
N ot es
Producing and absorbing vitamins Q U E S T I O N S
Forming and propelling feces toward
the rectum for elimination
Esophagus

D E T A I L S

Accessory Organs
S U M M A R Y

Functions of the Liver

Produces bile, albumin, and cholesterol
Converts glucose to glycogen for storage
Converts ammonia to urea
Metabolizes bilirubin in the breakdown of RBCs
Metabolizes drugs and toxins
Produces clotting factors and regulates blood clotting

Gallbladder K E Y T E R M S

Stores bile
Releases bile and pancreatic
enzymes into the small intestine
Duodenum
Bile
Greenish, yellowish, or
brown substance
Very alkaline
Emulsifies lipids to allow
absorption
Secreted by liver
Stored by gallbladder

90
 Archer Review

N ot es
Q U E S T I O N S

D E T A I L S

Let’s meet our GI client…

S U M M A R Y

1/3/2019
Tom Jones

138/98
99.4°F /
37.4°C 86 22 Male
5’10” 268 lbs 38.4 98% RA 7 12 81

Presents to urgent care Alert and oriented, responding to questions.

today with a two-week Unlabored respirations, clear and equal
history of “stomach pain.” bilaterally. No respiratory distress noted on
When asked to point to the RA. S1S2, RRR. Pulses are +2 throughout, <3
pain he localizes to the RLQ. second capillary refill. Distended and tender
Reports pain is present after abdomen, pain localized to RLQ.
meals, but states it "is
slightly better after eating".
He denies nausea, vomiting,
K E Y T E R M S
or changes in bowel
patterns.

Let’s explore two possible causes

of Mr. Jones’ stomach pain.

91
 Archer Review

Causes
Gastric Ulcers N ot es
H. pylori Q U E S T I O N S
Overuse of NSAIDs
Symptoms
Pain 1-2 hours after meal
Abdominal pain aggravated by eating
Vomiting
Weight loss
D E T A I L S
Hematemesis (if hemorrhage occurs)
Treatments
Treat the H. pylori infection
Antibiotics
Reduce stomach acid
H2 receptor blocker
Proton pump inhibitor

Duodenal Ulcers
Causes
H. pylori
Overuse of NSAIDs
Symptoms
Pain 2-4 hours after meals
Temporary relief of pain following
food intake
Weight gain S U M M A R Y
Melena (if hemorrhage occurs)
Treatment
Treat the H. pylori infection
Antibiotics
Stomach acid reduction
H2 receptor blocker
Proton pump inhibitor

Based on Mr. Jones'

presentation, which type of ulcer
would be most likely?

Gastric Ulcer Duodenal Ulcer

K E Y T E R M S

Location Stomach Duodenum

Causes H. Pylori, NSAID overuse H. Pylori, NSAID overuse

Pain 1-2 hours after meal 2-4 hours after meal

Eating Aggravates pain Relieves pain

Vomiting, weight loss,

Symptoms Weight gain, melena
hematemesis

Antibiotics, PPI, H2- Antibiotics, PPI, H2-

Treatment
receptor blocker receptor blocker
92
 Archer Review

Now, let’s look at some of Mr.

Jones's treatment options. Notes
Q U E S T I O N S
Antiulcer Agents
H2 Receptor Blockers Antacids
Famotidine Calcium carbonate
Cimetidine Magnesium hydroxide
Nizatidine Bismuth subsalicylate
Proton Pump Inhibitors GI Protectant D E T A I L S
Omeprazole Sucralfate
Lansoprazole
Pantoprazole

Famotidine
Therapeutic class: H2 receptor antagonist, antiulcer, antihistamine
Indication: Short-term treatment of gastric and/or duodenal ulcers, GERD,
Zollinger-Ellison syndrome, hypersecretion of stomach acid conditions, chronic
NSAID/ASA use, and/or GI distress
Action: Blocks the release of histamine. Histamine is found in mast cells within
the GI mucosa and causes gastric acid and pepsin secretion when it binds with H2
receptors in the mucosal parietal cells; When blocked, acid secretion is blocked
Nursing Considerations:
Monitor CBC and kidney function
Can be given with meals
Peak absorption of famotidine is within 2-3 hours
S U M M A R Y
Famotidine is available OTC in lower strengths than prescription dosages
Teach clients only to take as directed and only for a short duration
Due to the low number of drug interactions, famotidine is a drug of choice
for clients on multiple medications (including those with therapeutic/toxic
drug level concerns, such as phenytoin and warfarin)

Omeprazole
Therapeutic class: Proton pump inhibitor, anti-ulcer agent
Indications: GERD, treatment of gastric and/or duodenal ulcers
Action: prevents the transport of H+ ions into the gastric lumen by binding to
gastric parietal cells to decrease gastric acid production
Nursing Considerations:
Administer 30-60 minutes before meal
Report black, tarry stools

Sucralfate
K E Y T E R M S
Therapeutic class: Gastrointestinal protectant, anti-ulcer agent
Indications: GERD, treatment of gastric and/or duodenal ulcers, peptic
esophagitis
Action: Provides barrier for ulcers by creating a paste when exposed to
hydrochloric acid; It binds to proteins that are excreted by damaged cells in
ulcerated tissue thereby protecting the mucosa
Nursing Considerations:
Administer sucralfate on an empty stomach, 1 hour before or 2 hours after
meals, or at bedtime (up to 4 times a day)
Avoid giving it within 30 minutes of antacids to maintain effectiveness
Sucralfate contains aluminum, and its use can lead to the accumulation of
aluminum in the body over time which can be significant for individuals
with impaired kidney function
Monitor blood sugar in diabetics using sucralfate (contains sucrose)
Separate sucralfate from warfarin, digoxin, phenytoin, levothyroxine, and
antibiotics by at least 2 hours to prevent reduced bioavailability
93
 Archer Review

Three months later… Notes

Q U E S T I O N S
Mr. Jones has made an appointment
at his PCP for some new symptoms.
D E T A I L S

4/3/2019

Tom Jones
98.4°F/
128/76 12 Male
36.9°C 76
5’10” 238 lbs 34.2 98% RA 7 12 81

Presents
Presentswith
to hiscontinued
PCP with Alert
Alertand
andoriented,
oriented,responding
responding toto
questions.
questions.
continuedpain.”
“stomach “stomach pain.”
Diagnosed Unlabored
Unlaboredrespirations,
respirations,clear
clear and
andequal
equal
Wasduodenal
with diagnosed with three
ulcers bilaterally.
bilaterally.NoNorespiratory
respiratorydistress
distressnoted onon
noted
duodenal
months agoulcers 3 months
and put on RA.
RA.S1S2,
S1S2,RRR.
RRR.Pulses
Pulsesare are+2+2 throughout,
throughout,<3
ago and put
sucralfate, on sucralfate,
famotidine, and second capillary
<3 second refill.refill.
capillary Distended and tender
Distended and
famotidine and
omeprazole. Reports abdomen, pain throughout
tender abdomen, abdomen,abdomen
pain throughout which
omeprazole.
medication Has not had
compliance, but client describes
described as "crampy."
as crampy. DiarrheaAccording to
with each
much improvement
states he has not hadand much the client,
meal per diarrhea occurs with each meal.
patient report.
states has continued
improvement. Denies his S U M M A R Y
medications
nausea, as instructed.
but reports he has
No nausea,
begun has started to
to experience
have diarrhea
diarrhea withmeal.
with each each
meal.

Let’s explore two more possible

diagnoses for Mr. Jones… It’s always
possible something was missed at the
urgent care visit three months ago or the
client’s condition has changed since the
initial evaluation, especially when the
client's symptoms have continued for this
long and have not responded to K E Y T E R M S

treatment as expected!

Ulcerative Colitis
Inflammation of the large intestine

Typically begins in the

rectum and progresses
up the sigmoid colon

94
 Archer Review

Crohn's Disease Notes

Inflammation AND erosion Q U E S T I O N S
anywhere throughout the
small and large intestines

D E T A I L S

Assessment
Rebound tenderness
Cramping
Diarrhea
Vomiting
Dehydration
Weight loss
Rectal bleeding
Bloody stools
Anemia
Fever

.
Treatment S U M M A R Y

Low fiber diet

Avoid cold or hot foods
Smoking cessation
Antidiarrheals
Antibiotics
Steroids Colostomy Ileostomy
Severe cases may need surgical
removal of the affected portion of the
intestines
Ileostomy
Colostomy

Nasogastric Tube (NGT)

Tube inserted into the nare that K E Y T E R M S
terminates in the stomach
Uses:
Enteral nutrition
Decompression
Medication administration
Removal of stomach
contents after an overdose
or accidental ingestion

95
 Archer Review

Measurement
Notes
Q U E S T I O N S
nose
NG tube insertion is
NOT fun for the client.
Warn your client that it earlobe
will be uncomfortable!!
D E T A I L S

xiphoid process

Placement Verification
Gold standard - x-ray visualization
Aspiration of gastric contents
Auscultation of air over the epigastrium
Residuals
The amount of tube feed remaining in the client's stomach at the
time of the next assessment
Typically assessed when preparing to initiate the client's next feed

S U M M A R Y

If the residual is greater than ,

the tube feed should be held.

Colostomy and Ileostomy Care

Empty the pouch when ⅓-½ full
Change the pouch every 3-5 days
Keep the stoma clean and moist
Assess peristomal skin closely for
breakdown

Total Parenteral Nutrition (TPN) K E Y T E R M S

TPN is best
administered via
central line!

96
 Archer Review

Central Venous Catheter (CVC)

Superior vena cava Notes
Central line Q U E S T I O N S
catheter

D E T A I L S

Potential TPN Complications

Big infection risk Scrub that hub! Wash your hands!! Gloves!!!
Bag and tubing is changed every 24 hours
Refrigerated until ready to hang

Fluid overload Daily weights

Check electrolytes
Hyper OR hypoglycemia Do not turn on or off suddenly
If you run out of TPN give Dextrose 10%
S U M M A R Y
at the SAME rate the TPN was running
Titrate up when turning on and down when
turning off
Check blood glucose levels every 4-6 hours

Embolism

Appendicitis
Inflammation of the appendix Healthy
Most common age = 10 years appendix
Most common abdominal surgery in
children
Perforation is more common in children
Diseased
appendix

Appendicitis Pain K E Y T E R M S

Begins as a dull, steady periumbilical pain

Over 4-6 hours, pain progresses and localizes
to right lower quadrant (RLQ)
Rebound tenderness: pain when pressure is
removed, rather than applied
Sudden relief of pain
may indicate appendix
rupture (which can
lead to peritonitis)

97
 Archer Review

NCLEX Question
The nurse is reassessing their client diagnosed with appendicitis. The client
expressed 8/10 pain at her last assessment, and now states they has no pain. The
Notes
nurse did not administer any pain medication. What is the critical nursing action? Q U E S T I O N S

A. Document the pain score

B. Assess the client's abdomen
C. Notify the primary healthcare provider
D. Palpate McBurney’s point
D E T A I L S

Answer: C
C is correct. The nurse should immediately notify the primary healthcare provider
of this change in the client's status. A sudden change of 8/10 pain to no pain in the
client diagnosed with appendicitis could indicate rupture, and the primary
healthcare provider needs to be immediately notified.
A is incorrect. When a client diagnosed with appendicitis has sudden relief of pain,
it is a sign of possible rupture of the appendix. This is a surgical emergency and the
client must be taken to the operating room quickly. It is not appropriate for the
nurse to document the pain score without further intervention.
B is incorrect. It is not appropriate to simply assess the client's abdomen without
further intervention. Sudden relief of pain is concerning for rupture of the appendix
and requires another action.
D is incorrect. The client with appendicitis will likely have pain at McBurney’s point,
but this client is expressing a sudden relief of their pain. This needs to be evaluated
for possible rupture, and therefore the nurse should immediately notify the primary
healthcare provider. S U M M A R Y

Test
Taking When faced with a test question that
Tip! suggests "notify the provider," remember
that this action should be considered when
there is nothing within the nurse's scope of
practice or immediate actions that can
directly assist the client.

Treatment
Surgical intervention: appendectomy

Pre-op Post-op
Avoid heat - this can IV fluids
K E Y T E R M S
aggravate inflamed IV antibiotics
appendix and cause rupture Pain management
Position onto right side, NPO until bowel sounds return
low Fowler’s for comfort Wound care

Ondansetron
Therapeutic class: Antiemetic
Indications: Nausea/vomiting
Action: blocks effects of serotonin on vagal nerve and CNS
Nursing Considerations:
Administer slowly
Fast push can cause QT prolongation and/or ventricular tachycardia
98
 Archer Review

Pancreatitis
Notes
Inflammation of the pancreas Q U E S T I O N S
Leading cause = alcoholism

Pathophysiology
Digestive enzymes activate inside of
the pancreas, resulting in autodigestion
of the pancreas D E T A I L S

Assessment
Pain
Increases with eating due to increased enzymes
Abdominal distention
Ascites
Abdominal mass
Rigid abdomen Labs
Cullen’s sign Increased WBCs
Grey Turner’s sign Increased serum
Fever lipase and amylase
Nausea and vomiting
Jaundice
S U M M A R Y
Hypotension

Cullen’s sign

Grey Turner’s
sign

Pancreatitis Nursing Interventions

K E Y T E R M S

99
 Archer Review

Here are Mr. Jones’s results: Notes

Q U E S T I O N S

D E T A I L S

Based on these lab results, what other organ do

we need to ALSO be worried about?!?!
The leading causes of
damage to the liver are
alcohol or infection. S U M M A R Y

Hepatitis
Inflammation of the liver
Can progress to cirrhosis
Types A, B, C, D, and E - caused by
different viral infections
Severe cases can lead to a hepatic coma
(hepatic encephalopathy) or even death

Types of Viral Hepatitis

Transmission Prevention Treatment

K E Y T E R M S
Contaminated food or water Vaccination, improved Supportive
(fecal-oral) hygiene and sanitation (typically self-limiting)

Acute: supportive
Contact with infected body fluids Vaccination, blood
Chronic: antiviral therapy
(ie. blood, semen, vaginal fluids) screening, improved hygiene
with/without interferon

Contact with infected body fluids Blood screening, sanitary

Direct-acting antivirals
(ie. intravenous drug use, non- healthcare environment,
(DAAs)
sterilized medical equipment) sterile needles for injections

Contact with infected body fluids No specific treatment

Blood screening, sterile
*can only be infected with HDV available, pegylated
needles for injections
if already infected with HBV interferon may help

Contaminated food or water Improved hygiene Supportive

(fecal-oral) and sanitation (typically self-limiting)

100
Hepatic Encephalopathy
N ot es
Protein in your diet is broken down into ammonia Q U E S T I O N S
A functioning liver converts the ammonia into urea
Kidneys excrete urea
When there is inflammation of the liver due to hepatitis, the ammonia
builds up instead of being converted to urea
Increased ammonia levels can cause a hepatic coma
D E T A I L S

Treatment S U M M A R Y
Decrease ammonia
Lactulose
Bacteria in the colon digest lactulose into chemicals that bind
ammonia
The binding of ammonia prevents ammonia from moving from
the colon into the blood
Allows the ammonia to be excreted through stool
Antibiotic (neomycin or rifaximin)
Reduces bacterial production of ammonia
Decreased protein in diet
Monitor serum ammonia
Decrease fluid retention
Potassium-sparing diuretics
Avoid CNS depressants
Benzodiazepines and opioids can worsen the encephalopathy

Cirrhosis
K E Y T E R M S
A chronic disease of the liver marked by degeneration of cells, inflammation,
and fibrous thickening of tissue
Liver cells are destroyed and replaced with scar tissue
This impairs blood flow to the liver, often causing portal hypertension
Causes:
Chronic alcohol abuse
Chronic viral hepatitis
Fatty liver disease

Healthy Liver Diseased Liver

101
 Archer Review

Cirrhosis Assessment N ot es
Q U E S T I O N S

D E T A I L S

Treatment
Antacids Be very careful with drug doses
Vitamins The liver cannot metabolize as
Diuretics well; most doses need to be
Paracentesis decreased
Low protein, low sodium diet Especially important with:
S U M M A R Y
Strict I&Os Narcotics
Daily weights Acetaminophen (as a rule,
Bleeding precautions avoid in liver clients)
Skincare

K E Y T E R M S

You finished GI!

Keep up the great work!

102
 ANSWER KEY -
GASTROINTESTINAL
Page 89 Pyloric sphincter Absorb nutrients
Page 90 Absorbs water Bile
Page 91 Regulates blood sugar
Page 92 Overuse of NSAIDs
2-3 hours tarry stools
Page 93
before 2 hours
Page 95 Inflammation Low fiber diet
Page 96 X-ray visualization 500mL 3-5 days
Hypo or hyperglycemia
Page 97 children
Sudden relief
Page 98 C heat slowly
Page 99 alcoholism Cullen’s sign
Page 100 viral
Page 101 ammonia levels lactulose depressants alcohol abuse

103
 Archer Review

N ot es
Q U E S T I O N S

D E T A I L S

Anatomy + Physiology Foley Catheter Insertion

Urinary tract Renal Disorders
Nephron UTI
Kidney functions Glomerulonephritis
RAAS system Nephrotic syndrome
Renal Pharmacology Renal failure
Sepsis
Dialysis
S U M M A R Y
Kidney Anatomy and Physiology
The Urinary Tract
Nephron
Kidneys Functional unit of the kidney
Glomerulus
Bundle of capillaries where the
filtration occurs in the nephron

Ureters

Bladder The Nephron

Proximal convoluted
Urethra tubule Distal convoluted
Renal corpuscle
tubule
Glomerulus
K E Y T E R M S

Renal
pelvis Bowman’s
Calyces capsule

Renal artery Renal

Renal vein medulla

Ureter Renal
Renal Collecting
cortex duct
artery

To ureter
Renal Loop of
vein henle

104
 Archer Review

Functions of the Kidney

Notes
Q U E S T I O N S

D E T A I L S

S U M M A R Y

Renal System Labs

BUN 10 - 20 mg/dL
Creatinine 0.6 - 1.2 mg/dL
GFR >90 mL/min

Renal Pharmacology
K E Y T E R M S

Diuretics
Bumetanide
Loop Furosemide
Diuretics Torsemide

Potassium-sparing Eplerenone
Diuretics Spironolactone

Thiazide Chlorothiazide
Diuretics Hydrochlorothiazide

105
 Archer Review

Loop Diuretics N ot es
Examples: Bumetanide, furosemide, torsemide Q U E S T I O N S
Indications: Increases urinary output, used to manage edema, CHF, and/or
blood pressure management
Action: Acts on the loop of Henle to increase urine output by affecting
sodium reabsorption within the nephron; inhibits the sodium-potassium-
chloride (Na-K-2Cl) co-transporter, causing sodium to be excreted in the
urine, resulting in increased urination D E T A I L S
Nursing Considerations:
Monitor potassium levels
These are the most effective of all diuretics

Potassium-Sparing Diuretics
Examples: Spironolactone, eplerenone
Indications: Hypertension, edema, swelling, hypokalemia
Action: Inhibits the sodium and potassium exchange via sodium channels in
the distal parts of the nephron: this 'spares' potassium
Nursing Considerations:
Monitor potassium levels
These medications are not as strong as other diuretics, so potassium-
sparing diuretics are often combined with a loop or thiazide diuretic

S U M M A R Y
Thiazide Diuretics
Examples: Chlorothiazide, hydrochlorothiazide
Indications: Hypertension, CHF
Action: Acts on the distal convoluted tubule to inhibit the sodium-chloride
(Na-Cl) co-transporter, decreasing sodium reabsorption and resulting in
increased fluid loss via urination
Nursing Considerations:
Monitor electrolyte levels
Monitor blood pressure

Epoetin Alfa
Examples: Erythropoietin
Therapeutic class: Erythropoiesis-stimulating medications
Indication: Severe anemia (including severe anemia caused by chronic renal
disease)
Action: Binds to specific receptors on the surface of its target cells to induce
erythropoiesis; induces hemoglobin formation K E Y T E R M S
Nursing Considerations:
Requires several weeks to be effective
High risk for BLOOD CLOTS
Stroke
Pulmonary Embolism
Headache
Hypertension

Study Make flashcards for each medication

Tip so you can study on the go!

106
Foley Catheter
N ot es
Q U E S T I O N S
What is a Foley Catheter?
Catheter placed into the client's
bladder via the urethra
Foley catheters are 'indwelling'
or left for an extended period D E T A I L S
Urine drains to gravity into a
drainage bag

Required Nursing Knowledge

There should never be dependent loops in the tubing, as this can lead to
urine backing up into the bladder
Inserting a Foley catheter requires a sterile technique to prevent infection
CAUTIs (catheter-associated urinary tract infections) are UTIs occurring in
a client whose urinary bladder is catheterized or has been catheterized
within the past 48 hours
Facilities are not reimbursed for care provided to clients diagnosed
with a CAUTI; there is a great deal of emphasis on prevention
Most facilities utilize a bundle for CAUTI prevention
Always remove catheters as soon as medically possible
Daily cleaning and care
You can collect a urine sample directly from the port on the Foley! S U M M A R Y

Urinary Tract Infection (UTI)

An infection in any part of the
urinary system
Kidneys
Pyelonephritis
Ureters
Bladder
Cystitis
Urethra
Most common = lower UTI
Treatment
(bladder, urethra) Hydration: Drink LOTS of
Women are more susceptible water!
due to shorter urethra length Cranberry juice?
and proximity to anus No conclusive evidence
this really helps!
Assessment Antibiotics K E Y T E R M S

107
 Archer Review

Glomerulonephritis
N ot es
Q U E S T I O N S
What is
Glomerulonephritis?
An acute or chronic
D E T A I L S
inflammation of the kidney
at the level of the nephron!

Bowman’s
capsule
Pathophysiology
There is an inflammatory reaction in the
glomerulus of the kidney
Antibodies lodge in the glomerulus,
resulting in decreased filtering capability
of the kidney(s)
Usually caused by an infection
#1 cause is Streptococcus

Assessment S U M M A R Y

Sore throat
Malaise
Headache
Flank pain
Hypertension
Edema (peripheral or periorbital)
Decreased UOP
Increased urine specific gravity
Sediment in urine
Hematuria
Increased BUN and creatinine

Treatment

K E Y T E R M S

108
 Archer Review

NCLEX Question
The nurse is reviewing the assessment data for a client with acute
glomerulonephritis (AGN). Which of the following would be an anticipated finding?
N ot es
Q U E S T I O N S
a. Ketonuria
b. Hematuria
c. Polyuria
d. Glycosuria Answer: B
Choice B is correct. Clinical features of acute glomerulonephritis (AGN) include D E T A I L S
proteinuria, hematuria, periorbital edema, weight gain, high blood pressure, and/or
decreased glomerular filtration rate (GFR).
Choices A, C, and D are incorrect. Individuals with glomerulonephritis would
have oliguria, not polyuria, due to the significant amount of inflammation in the
glomerulus. Although glycosuria and ketonuria are not features of this disease,
they are traditionally seen in clients with uncontrolled blood glucose.
Additional information: AGN is a serious condition that typically occurs secondary
to an infectious process including, but not limited to, streptococcal, Staphylococcus
aureus, or hepatitis. Nursing care aims to prevent the most common complication
of fluid volume overload by enforcing the client's dietary restrictions (i.e., fluid,
sodium, and/or potassium). The nurse should closely monitor the client's intake
and output, weight, and blood pressure.

Nephrotic Syndrome S U M M A R Y

What is Nephrotic Syndrome?

A kidney disorder that causes the body to pass too much protein into the urine
Causes:
Infection: Bacterial or viral
NSAIDS
Cancer
Lupus
Diabetes
Strep
INFLAMMATION

Pathophysiology
Large holes in the glomerulus form, allowing
An inflammatory response protein to leak from the blood into the urine
in the glomeruli Proteinuria K E Y T E R M S
Hypoproteinemia

THE RESULT:
RAAS kicks in to replace low
No protein in the blood? Client
blood volume
cannot keep fluid in blood vessels
Causes retention of sodium
THIRD SPACING and water

RAAS system triggered

Fluid collects in tissues,
low circulating blood volume
109
 Archer Review

Assessment N ot es
Anasarca Q U E S T I O N S
Blood clots
High cholesterol

Proteinuria
Hypoalbuminemia
Edema D E T A I L S
Hyperlipidemia

Treatment
Diuretics
ACE inhibitors
Prednisone
Statins
Anticoagulants
Dialysis
Diet
Low protein
Low sodium
S U M M A R Y

Renal Failure
Causes
Pre-renal: Blood cannot get to the kidney(s)
Hypotension
Hypovolemia
Shock
Intra-renal: There is damage inside of the kidney(s)
Glomerulonephritis
Nephrotic syndrome
Nephrotoxic drugs
Contrast
Aminoglycosides
Post-renal: Something is blocking urine from
leaving the kidney(s)
Kidney stone K E Y T E R M S
Tumor
Urethral obstruction
Enlarged prostate

110
 Archer Review

Acute
Acute Kidney Injury (AKI) or Acute Renal Failure (ARF)
N ot es
Sudden Q U E S T I O N S
Happens over a few hours or a few days
Causes a build-up of waste products in the blood

D E T A I L S

Chronic
Chronic Kidney Disease (CKD)
Occurs slowly over a long period
Damage to the kidneys accumulates over time
Can no longer filter waste properly
Waste products build-up

BPH S U M M A R Y

Assessment

K E Y T E R M S

Types of Dialysis
A form of renal replacement therapy that removes
the body's unwanted toxins, waste products,
and excess fluids by filtering the blood.

Hemodialysis

Peritoneal Dialysis

111
 Archer Review

Hemodialysis (HD)
Performed 3-4 times per week
Clients must be anticoagulated
N ot es
Will cause rapid fluid shift (300-800 mL/min) Q U E S T I O N S
Monitor BP
Monitor electrolytes
Not all clients can tolerate
Clients must have a fistula
No BPs/IV sticks in the arm of the fistula
Palpate a thrill D E T A I L S
Auscultate a bruit
Heparin pump Dialyzer inflow
(to prevent clotting) pressure monitor
Used
dialysate
Arterial
pressure Blood
monitor pump

AV Dialyzer
fistula Venous pressure
monitor

Automatic clamp Dialysate

Air trap and
detector

Peritoneal Dialysis (PD) S U M M A R Y

Uses the peritoneal membrane as the filter instead of a machine

Process:
Dialysate is infused into the peritoneal cavity (2,000-2,500 mLs)
Dwells for a specified time (approximately 6 hours)
Fluid is drained, taking the toxins along with it
Drainage should be clear
Cloudy drainage indicates an infection
Ensure all of the dialysate is drained
Instruct clients to turn side to side if experiencing decreased fluid
return
Peritoneal dialysis is better for clients who cannot tolerate the fluid shifts in
hemodialysis

K E Y T E R M S

You finished renal!

Keep up the great work!

112
 ANSWER KEY - RENAL
Page 104 Nephron
potassium levels blood pressure
Page 106
‘spares’ blood clots

Page 107 dependent infection antibiotics

inflammatory
Page 108
BUN and creatinine
B
Page 109
Inflammation
Proteinuria
Page 110 High protein
Shock

Page 111 Sudden

Rapid fluid shift

Page 112 bruit
Cloudy drainage

113
 Archer Review

N ot es
Q U E S T I O N S
SHOCK
C A U S E S O F
M U L T I O R G A N D E T A I L S

D Y S F U N C T I O N

Shock overview
Hypovolemic shock
Cardiogenic shock
Cardiac tamponade
Distributive shock
Sepsis

What is Shock? S U M M A R Y

A state where the vital organs are not receiving adequate oxygenation
This lack of oxygenation causes organ damage and forces the cells to use
anaerobic metabolism to create energy
Produces a by-product called lactate
Cardiovascular system is composed of:
The blood
Blood Vasculature Heart
Cardiovascular system
\
is composed of
The vasculature
The heart
A disruption in any of these three components can cause a lack of oxygen
delivery to the organs, causing shock
Whichever component is ‘broken’ determines the type of shock

Types of Shock
K E Y T E R M S

114
 Archer Review

Hypovolemic Shock
N ot es
Q U E S T I O N S
Pathophysiology
Low blood flow
There is a loss of the circulating volume
Not enough blood to enter the heart (preload),
which decreases cardiac output D E T A I L S
The body will vasoconstrict to compensate
Not enough blood gets to the tissues
Not enough oxygen gets to the tissues
Anaerobic metabolism
Shock

S U M M A R Y

Causes of Hypovolemic Shock

Dehydration Burns Hemorrhage Traumatic injury

K E Y T E R M S
(Vomiting, diarrhea)

115
 Archer Review

Blood Administration
Blood is administered as a medication… so follow the N ot es
same “rights”! Q U E S T I O N S
Checked by 2 RNs to ensure compatibility and
correct order
Client should have an active Type &
Screen to determine compatibility
Blood should be administered with special blood
tubing that has a filter with a larger gauge IV
Normal saline is the approved compatible IV D E T A I L S
fluid to infuse with/after blood
Ensure vital signs are taken before, during, and after
infusion per hospital policy
Baseline vitals are crucial to determine if your
client is having a reaction!!
Closely monitor client for the first 30 minutes, which
is the most likely time a reaction could occur

Cardiogenic Shock
The heart fails to pump sufficient blood out to the
organs
“Pump failure”
Something is stopping the heart itself from getting
blood out to the body
Not enough blood gets to the tissues S U M M A R Y
Not enough oxygen gets to the tissues
Anaerobic metabolism
Shock

Causes
MI
Heart failure
Myocarditis
Endocarditis
Cardiomyopathy
Drug toxicity

Obstructive
K E Y T E R M S
Cardiogenic
Shock
Examples:
Cardiac tamponade
Pulmonary embolism

There is a physical
OBSTRUCTION which causes the
heart to fail to pump sufficient
blood out to the organs

116
 Archer Review

Cardiac Tamponade
Too much fluid builds up in the pericardial space
N ot es
Q U E S T I O N S

Leads to increased
pressure in the heart
Symptoms
Muffled heart
sounds D E T A I L S
Jugular vein
distension
Hypotension
Pericardial rub
Treatment
Pericardiocentesis

Cardiogenic Shock Assessment

S U M M A R Y

Cardiogenic Shock Treatment

TREAT THE CAUSE
MI
PCI
CABG
PE K E Y T E R M S
Thrombolytics
Cardiac tamponade
Pericardiocentesis
Improve contractility
Dopamine
Dobutamine
Decrease afterload
Diuretics
Dobutamine

Pericardiocentesis

117
 Archer Review

Distributive Shock
N ot es
Pathophysiology Q U E S T I O N S

Something causes an immune or autonomic response

in the body
This alters vascular tone
The result is massive peripheral vasodilation
With so much vasodilation, the blood pressure is D E T A I L S
inadequate to provide blood flow to the vital organs
Not enough blood gets to the tissues
Not enough oxygen gets to the tissues
Anaerobic metabolism
Shock

Causes and Treatments

S U M M A R Y

Assessment
Decreased oxygen
Hypotension
Tachycardia
Tachypnea
Warm, flushed skin
Decreased LOC

Sepsis
A systemic inflammatory K E Y T E R M S
What is sepsis?
reaction to an infection

Common Sepsis-Producing Infections

118
 Archer Review

Sepsis Pathophysiology
Notes
Q U E S T I O N S

D E T A I L S

S U M M A R Y
Assessment
Hypotension
Febrile
Tachypneic
Tachycardic
Change in level of
consciousness (LOC)
Hypoxic

Sepsis Treatment Timeline

K E Y T E R M S

As soon as sepsis Immediately upon If unresponsive

Within 60 hypotension
is recognized to IVF or fluid
minutes
Start broad- Isotonic IVF overload occurs
Draw blood
spectrum IV NS Epinephrine
cultures
antibiotics Rapid bolus Norepinephrine
2 sets Vasopressin
Vancomycin Assess
Start IV Dopamine
response
Repeat PRN

119
 ANSWER KEY - SHOCK
Page 114 lactate
Page 115 Anaerobic metabolism
2 RNs
“Pump failure”
Page 116
Drug toxicity
Cardiac tamponade
Jugular vein distension
Page 117 S3
Pericardiocentesis
peripheral vasodilation
Page 118 Septic
Warm, flushed skin
Page 119 Within 60 minutes

120
 Archer Review

N ot es
Q U E S T I O N S

D E T A I L S

Anatomy + Physiology Endocrine Disorders

Organs Addison’s & Cushing’s
Hormones DI & SIADH
Hypo- and hyperthyroidism
Hypo- and hyperparathyroidism
T1DM & T2DM

Organs of the Endocrine System S U M M A R Y

Endocrine Lab Values K E Y T E R M S

Glucose 70-110 mg/dL

HbA1c
Expressed as a percentage, measures
the average blood glucose over the
previous three months

Non-diabetic 4-5.6%
Pre-diabetes 5.7-6.4%
Diabetic >6.5%
Target HbA1c <7%
for diabetics
121
 Archer Review

N ot es
Q U E S T I O N S

D E T A I L S

Addison’s v.s.
Cushing’s Disease
Steroids
Produced by the adrenal cortex S U M M A R Y
Glucocorticoids - cortisol
Affect mood
Cause immunosuppression
Breakdown of fats and proteins
Inhibit insulin
Mineralocorticoids - aldosterone
Retention of sodium and water
Excretion of potassium
Sex hormones - testosterone,
estrogen, and progesterone

Hormone Disease

Not enough:
Steroids:
Addison's Disease
Glucocorticoids (cortisol)
Too much:
Mineralocorticoids (aldosterone)
Cushing's Disease

K E Y T E R M S

Thinning hair
Hair loss
Acne
Facial flush
Moon face
Fat pads
Hyperpigmentation GI disturbances (buffalo hump)
Purple striae,
Hypotension and abdominal Easy bruising
vascular collapse stretch marks

Hypoglycemia, Trunk obesity Thin arms and

weakness, and fatigue legs
Weight
loss Pendulous
abdomen

Hypofunction of the adrenal Hyperfunction of the

cortex due to destructive adrenal cortex caused by
process - most commonly, excessive anterior pituitary
autoimmune destruction. secretion of ACTH.
122
 Archer Review

Treatment
N ot es
Q U E S T I O N S

D E T A I L S

NCLEX Question
A nurse knows that in the event of an Addisonian crisis, it is most appropriate to
administer which of the following medications intravenously?

a. Insulin
b. Normal saline solution
c. Dextrose 5% in water
d. Dextrose 5% in half-normal saline solution

Answer: B
One problem of a client in the Addisonian crisis is hyponatremia. Therefore, the S U M M A R Y
nurse should anticipate administering 0.9% saline solution. Glucose, vasopressors,
and hydrocortisone are also used to treat the Addisonian crisis. It would be
inappropriate to administer insulin, dextrose 5% in water, or dextrose 5% in half-
normal saline solution for this client. The correct answer is option B, while options
A, C, and D are incorrect.

DI v.s. SIADH
Antidiuretic Hormone
Secreted from the pituitary gland
Pituitary gland is in the brain, between the eyeballs
Be on the lookout for these issues if a client has had:
Craniotomy
Head injury
Sinus surgery
Causes anti-diuresis: Holding onto WATER K E Y T E R M S
Only water is retained, no sodium!
Increased ADH Increased water
Antidiuretic hormone = ADH = Vasopressin

123
 Archer Review

Pathophysiology
N ot es
Q U E S T I O N S

D E T A I L S

S U M M A R Y

DI vs. SIADH Lab Values

K E Y T E R M S

124
 Archer Review

Treatment
N ot es
Q U E S T I O N S

D E T A I L S

NCLEX Question
A client suddenly develops syndrome of inappropriate antidiuretic hormone
(SIADH) after undergoing cranial surgery. Which manifestations should the nurse
expect to see from the client?

a. Edema and weight gain

b. Decreased urine production
c. Hypotension
d. Low urine specific gravity
Answer: B S U M M A R Y

B is correct. Decreased urine production is a finding of SIADH. Because of the

increase in ADH, there is an increased retention of free water and a decrease in
urine output.
A is incorrect. Because of free water retention, there is increased retention of water
in the intravascular space this triggers the kidneys to excrete sodium, balancing the
fluid status of the client. The client is euvolemic. Weight gain is seen, but
peripheral edema is not. This absence of peripheral edema is a specific finding of
SIADH.
C is incorrect. You would expect to see normal blood pressure in SIADH. Only free
water is retained, no sodium, and the body remains euvolemic. This means that
clients with SIADH are normotensive.
D is incorrect. A low urine specific gravity would be seen in DI, when the
production of ADH is decreased and the body secretes large amounts of dilute
urine. In SIADH, the body retains free water and makes small amounts of
concentrated urine, increasing the specific gravity.

Thyroid Disorders
K E Y T E R M S

Thyroid Hormones
Produced by the thyroid gland
There are two types: T3 and T4
Thyroid hormones = energy
Controlled by a negative feedback loop
Thyroid-stimulating hormone (TSH)
controls the release of T3 and T4
Low T3 and T4 cause high TSH
High T3 and T4 cause low TSH

125
 Archer Review
Hormone Disease

Thyroid Hormones:
Not enough thyroid hormone
& too much TSH: TSH
N ot es
T3
Hypothyroidism T3/T4 Q U E S T I O N S
T4

Pituitary Gland Hormone: Too much thyroid hormone

TSH & not enough TSH:
Hyperthyroidism
(Grave's Disease)
D E T A I L S

Hypothyroidism Low T3/T4 - High TSH

The body does not have enough thyroid hormone

Increased levels of TSH try to signal the thyroid to make more T3 and T4
Thyroid gland cannot secrete enough T3 and T4 despite high TSH
T3 and T4 continue to be low
The negative feedback loop is broken

Hyperthyroidism High T3/T4 - Low TSH

Also known as Graves’ disease

The body has too much thyroid hormone
Decreased levels of TSH
Anterior pituitary recognizes low TSH and signals to the thyroid gland to
secrete more T3 and T4
T3 and T4 continue to be secreted despite being high S U M M A R Y
The negative feedback loop is broken

When the pituitary sends too much TSH, the

thyroid produces less T3 and T4

When there is less T3 and T4, it tells the brain,

“Hey! We need more TSH to make T3 and T4!”

K E Y T E R M S

126
 Archer Review

Treatment
Hypothyroidism Hyperthyroidism N ot es
Q U E S T I O N S
Levothyroxine: Thyroid hormone Methimazole: antithyroid
medication
Take on an empty stomach Stops the thyroid from making
Take first thing in the T3 and T4
morning (take at the same Iodine compounds
time every day) Used to decrease the size and D E T A I L S
vascularity of the thyroid gland
Will take this forever Radioactive iodine therapy
Destroys thyroid cells
Can cause hypothyroidism
Thyroidectomy
Removal of all or some of the
thyroid gland
Depending on post-operative
lab values, thyroid replacement
therapy may be necessary

Parathyroid Disorders
Parathyroid Hormone
S U M M A R Y
Secreted by the
parathyroid glands
Causes calcium to be
pulled out of the bones
and into the blood
Causes an increase in
serum calcium

K E Y T E R M S
Hypoparathyroidism Hyperparathyroidism

The parathyroid glands do not The parathyroid glands

secrete enough PTH secrete too much PTH
There are low serum calcium There are high serum calcium
levels levels
Low serum calcium levels High serum calcium levels
cause high serum phosphorus cause low serum phosphorus
levels levels
Symptoms = think agitated Symptoms = think sedated

127
 Archer Review

Diabetes Mellitus
N ot es
Q U E S T I O N S

D E T A I L S

Insulin
Produced in the pancreas Key
point!
𝛃-islets of Langerhan Insulin acts like a key that
Acts as the ‘key’ to transport glucose unlocks the door to the
from the bloodstream to the cells cells... lets glucose in!
Allows the cells to use glucose as fuel S U M M A R Y

Normal glucose 70-110 mg/dL

Insulin receptor Glucose channel

Door’s open,
time to go
inside!

K E Y T E R M S

128
 Archer Review

Diabetes Mellitus - Type 1

Body has destroyed the beta cells of the
N ot es
pancreas that produce insulin Autoimmune disease - or Q U E S T I O N S
idiopathic

Little or no insulin in the body Onset usually before

adulthood
Very high levels of glucose in the D E T A I L S
bloodstream

No glucose can get to the cells for fuel

S U M M A R Y

Diabetic Ketoacidosis
There is no insulin to carry
glucose to the cells

Glucose builds up in the blood

(high BG)

Blood becomes hypertonic, causing

fluid to shift into the vascular space Polyuria

Kidneys work to filter this

excess fluid and glucose Polyphagia

Cells are not receiving any fluid Polydipsia

or glucose - they are starving
K E Y T E R M S
Without glucose for energy, cells
break down proteins and fat

This produces ketones,

which are acids

Causes metabolic acidosis

Kussmaul respirations
Blow off CO2
High serum potassium

129
 Archer Review

Diabetic Ketoacidosis Assessment

N ot es
Q U E S T I O N S

D E T A I L S

Interventions

IV fluids
Restore blood volume
Replace fluid losses
D5 1/2NS once glucose down to 250 to
prevent hypoglycemia and cerebral edema S U M M A R Y

IV insulin - continuous
Potassium replacement after initial hyperkalemia is
resolved
Insulin moves potassium back into cells!
Bicarbonate for severe acidosis

Diabetes Mellitus - Type 2

Either not enough insulin, insulin resistance, or bad insulin

Commonly found with clients who are overweight

Body can’t make enough insulin to keep up with the glucose

Progressive disorder, usually in adults

Assessment K E Y T E R M S

130
 Archer Review

Chronic Complications
Cardiovascular disease
Diabetic peripheral
N ot es
neuropathy Q U E S T I O N S
Diabetic autonomic
Diabetic retinopathy neuropathy

Stroke Diabetic nephropathy

D E T A I L S
Infection

Preventing Complications
Proper foot care and footwear Take medications as
prescribed consistently
Offload pressure points and
Smoking cessation
ensure quality wound care
Prevention
Avoid nephrotoxic
Water thermometer for medications
bathing
Diet and lifestyle changes -
Dry feet thoroughly and apply carbohydrate counting,
moisturizer (not between toes) exercise, etc.
S U M M A R Y

Treatment
Diet and Exercise Low carb, high protein and veggies
Exercise
Eat before exercising, exercise is when blood sugar is
at it’s highest

Oral agents Medications which work to decrease the amount of

circulating glucose
Improves how the body produces and uses insulin
Medications can increase insulin receptor sensitivity, or limit
glucose absorption/production
e.g., metformin, sitagliptin, liraglutide, proglitazone

Insulin Mix of rapid and long acting insulin to absorb glucose K E Y T E R M S

from bloodstream

HHNS
Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS)

Exacerbation of Diabetes Mellitus Type II

Symptoms begin over days to weeks (v.s. hours for DKA)

131
 Archer Review

HHNS Pathophysiology
Notes
Q U E S T I O N S
Extremely high blood glucose levels

Blood becomes hyperosmolar

D E T A I L S
Kidneys start producing more urine due to the
hyperosmolarity of blood

Polyuria → dehydration → shock

No ketones

Acute Treatments
INSULIN IV FLUIDS ELECTROLYTES
Move that glucose Restore Replace electrolytes,
back into the cell! intravascular especially potassium
Also moves volume
potassium back High BG S U M M A R Y
into the cell caused a fluid
shift out of the
vascular space!

Long Term Treatments

DIET & EXERCISE ORAL AGENTS INSULIN
Low carb - Work to decrease the Basal bolus system
complex carbs amount of circulating Long-acting agent
Proteins & veggies glucose given once per day
Eat before Improves how the Rapid-acting agent
exercising body produces given with meals
Exercise when insulin and uses to cover the
blood sugar is at insulin carbs eaten
its highest Metformin
Establish a routine

K E Y T E R M S
Case Study
You arrive at work, and your first client arrives. It is a 22-year-old
female who complains of severe hunger and thirst, 9/10 abdominal
pain, headache, and a recent unexplained weight loss of 10 lbs.

What diagnosis is your initial concern? Why?

Describe the pathophysiology of this disease process on a cellular level.

132
 Archer Review

Case Study Continued N ot es

The following lab values result: Q U E S T I O N S
Interpret each lab result. Which lab
result are you most concerned about?
Explain WHY it is abnormal based on
the pathophysiology of DKA.

D E T A I L S

What diagnosis can be made

based on the lab results? There
is an underlying diagnosis and
an acute complication!

S U M M A R Y

Diabetic Ketoacidosis Treatment

K E Y T E R M S

133
 Archer Review

Case Study Continued

The healthcare provider confirms that your client is diagnosed with Notes
type I diabetes mellitus and is currently in diabetic ketoacidosis. They
Q U E S T I O N S
consult endocrinology for assistance and begin initial treatment. You
proceed, review the orders, and begin treatment.

What treatment would you expect to start in the ED?

D E T A I L S

Review each of these orders. You receive the following

Are they appropriate? orders from the HCP:
Is there anything you need to
Order Frequency
question or clarify?
Are there any additional
interventions you should ask ABG Q1 hr
for an order for?
BMP Q2 hrs

IV 100 ml/hr
Normal Saline
continuous S U M M A R Y

0.1U/kg/hr
Insulin Aspart continuously
via IV

K E Y T E R M S

For a basal-bolus system, what two types of insulin are prescribed?

Explain to the client how they work, and when he will administer them.

134
 Archer Review

Insulin Storage
Keep away from heat and direct sunlight
Notes
Never freeze insulin Q U E S T I O N S
Store in the refrigerator until ready for use
When actively using, keep it at room temperature
At room temperature:
NPH: Good for one month
Glargine: Good for 28 days
Rapid and short-acting: Good for 28 days D E T A I L S

Mixing Insulin
1 Draw up air equal to the total amount of insulin needed

2 Inject the correct amount of air into the NPH vial

3 Inject the remaining air into the regular insulin

4 Draw up the correct amount of regular insulin

5 Draw up the correct amount of NPH insulin

S U M M A R Y

Clear, then cloudy

(regular 1st, NPH 2nd!)
NEVER mix long-acting insulin

Insulin Administration
Only regular insulin can be administered IV
All others given SubQ
Rotate sites
Syringes measured in units
Never use expired or cloudy insulin
NPH is the only cloudy insulin

Subcutaneous Injection Sites

K E Y T E R M S

Outer aspect of
Back
the upper arm
Peri-umbilical area
of the abdomen
Buttock

Upper outer
thigh

135
 Archer Review

Angle of Injection
Subcutaneous
N ot es
Q U E S T I O N S
Injection

Bunched skin

Epidermis
D E T A I L S
Dermis
Stretched skin
Hypodermis

Muscle Muscle

Hypoglycemia
When there is not enough
glucose in the bloodstream Assessment
Blood glucose <70 mg/dL
Causes: Cold S U M M A R Y
Not enough food Clammy
Too much insulin Confused
Too much exercise Shaky
Nervous
45 mg/dL Nausea
Headache
Hungry
Blurry vision

Treatment
After the blood
glucose rises, eat a
snack with complex
carbs/proteins to
help maintain the
15 grams Wait 15 Still < 70? blood glucose level
of carbs (i.e., crackers with K E Y T E R M S
minutes, check Take another 15
peanut butter)
BG again grams of carbs

What if the client’s unconscious?!

If you have IV access

The priority is to push D50W to raise the client’s blood sugar.

If you do not have IV access

Administer IM glucagon. IM glucagon is a catabolic hormone that
raises glucose concentration in the bloodstream.

136
 Archer Review

Case Study Continued

The client later tells you that her grandfather was obese and N ot es
developed diabetes in his late 70s. She tells you that her
Q U E S T I O N S
grandfather also took a pill to control his blood sugar, and asks if
she could do that instead of the insulin injections.

What type of diabetes did the client’s grandfather have?

Explain how this differs from Type I diabetes.
D E T A I L S

Explain to the client how oral antidiabetic agents work.

Will this work for this client? Why or why not?

S U M M A R Y

What angle do you use

to give a subcutaneous
injection on a client with
an average BMI?

K E Y T E R M S

You finished endocrine!

Great work!

137
 Archer Review

ENDOCRINE
CASE STUDY ANSWERS
You arrive at work, and your first client arrives. It is a 22-year-old female who complains of
severe hunger and thirst, 9/10 abdominal pain, headache, and a recent unexplained weight
loss of 10 lbs.

What diagnosis is your initial concern? Why?

You should be concerned that this client possibly has diabetes mellitus and is in diabetic ketoacidosis (DKA). The
client's complaints of severe hunger (polyphagia) and severe thirst (polydipsia) are very specific complaints
indicative of diabetes. Moreover, the client's abdominal pain, headache, and recent weight loss should focus your
initial concern not only on diabetes mellitus but on a diagnosis of DKA.

Describe the pathophysiology of this disease process on a cellular level.

DMTI is an autoimmune disease. The body has destroyed the beta cells of the pancreas that produce insulin,
resulting in little or no insulin remaining in the body. Without insulin, there are very high levels of glucose in the
bloodstream. Insulin acts like a key to unlock the cells and carry glucose into the cells. Without insulin, glucose cannot
enter the cells for fuel. With DKA, there is absolutely no insulin to carry glucose to the cells. Glucose builds up in the
blood (high blood glucose), causing the blood to become hypertonic and fluid to shift into the vascular space. The
kidneys work to filter this excess fluid and glucose, causing polyuria. The cells are not receiving any fluid or glucose,
resulting in polydipsia and polyphagia. Since cells don’t have any glucose for energy, they metabolize proteins and fat
for energy, producing ketones (i.e., an acid). This build-up of the ketones causes metabolic acidosis. The body starts
breathing harder and faster to blow off CO2 and compensate for metabolic acidosis (i.e., Kussmaul respirations).
Lastly, because glucose can’t enter the cells, potassium also can’t get into the cells (most potassium is intracellular,
stored inside the cells). It enters the cells WITH glucose and cannot enter on its own. Without insulin, no glucose can
enter the cells, and therefore no potassium, leading to a high serum potassium level.

Interpret each lab result. Which lab result are you most concerned about?
Explain WHY it is abnormal based on the pathophysiology of DKA.

138
 Archer Review

ENDOCRINE
CASE STUDY ANSWERS
Interpret each lab result. Which lab result are you most concerned about?
Explain WHY it is abnormal based on the pathophysiology of DKA.

What diagnosis can be made based on the lab results?

There is an underlying diagnosis and an acute complication!
This client has diabetes mellitus type I and is experiencing the complication of
diabetic ketoacidosis (DKA).

The healthcare provider confirms that your client is diagnosed with

type I diabetes mellitus and is currently in diabetic ketoacidosis.
They consult endocrinology for assistance and begin initial
treatment. You proceed, review the orders, and begin treatment.
What treatment would you expect to start in the ED?
The major treatments to be implemented in the ED are close lab monitoring, IV fluids, and an insulin drip. For
labs, you would expect to monitor hourly blood glucose, serum potassium, and ABG to evaluate the metabolic
acidosis. For fluids, NS is used to start, and when the blood glucose lowers to the 250-300 range, D5W is added to
the solution to prevent hypoglycemia. The goal is to lower blood glucose slowly to prevent a rapid drop that
would cause fluid shift into the cells and potentially cause cerebral edema. Lastly, insulin must be administered to
decrease blood glucose. Administering insulin will bring glucose and potassium back into the cell, reducing the
client's blood glucose and serum potassium levels.

139
 Archer Review

ENDOCRINE
CASE STUDY ANSWERS
Order Frequency Appropriate
Review each of these
orders. Are they Yes. Monitoring the ABG every hour to evaluate the
appropriate? Is there ABG Q1 hr metabolic acidosis is very appropriate. No
anything you need to clarification needed.
question or clarify? Are
there any additional No. A full BMP every 2 hours isn't needed. Rather,
interventions you should we need hourly monitoring of the glucose and serum
potassium. The RN might clarify if there is an
ask for an order for? BMP Q2 hrs additional reason the HCP ordered a full BMP, but it
can likely be changed to just blood glucose and
potassium hourly.

Yes. Normal saline is the fluid of choice when

Normal IV 100 ml/hr starting fluid resuscitation in DKA clients. This will
Saline continuous help offset the massive fluid loss due to polyuria,
preventing hypovolemic shock.

No. This order is not appropriate. Insulin aspart is

0.1U/kg/hr RAPID-acting insulin and can NOT be administered
Insulin intravenously. Regular insulin is the only insulin that
continuously can be administered in this manner. The RN should
aspart
via IV clarify this order and should NOT administer the
insulin aspart intravenously.

For a basal-bolus system, what two types of insulin are prescribed?

Explain to the client how they work, and when he will administer them.
In a basal-bolus dosing system, long-acting and rapid-acting insulin will be prescribed.
The long-acting agent will be given once per day. The rapid-acting agent will be given with
meals to cover the carbohydrates the client eats.

The client later tells you that her grandfather was obese and developed diabetes
in his late 70s. She tells you that her grandfather also took a pill to control his
blood sugar and asks if she could do that instead of the insulin injections.

What type of diabetes did the client’s grandfather have?

The client's grandfather most likely had type II diabetes mellitus. In this type of
diabetes, there is either insufficient insulin, insulin resistance, or bad insulin. It is
commonly found in clients who are overweight, as their bodies are unable to
produce enough insulin to keep up with the glucose they take in. This differs
from type I, where the body doesn't have ANY insulin, due to the destruction of
the beta cells of the islets of Langerhans in the pancreas.
Day 2,
Explain to the client how oral antidiabetic agents work.
Will this work for this client? Why or why not?
done!
Oral anti-diabetic agents like this client's grandfather took work to decrease
circulating glucose in the client's body. They improve how the body produces
and uses insulin, making them an excellent adjunct to treating type II diabetes.
See you tomorrow
This is because, in type II diabetes, there is either not enough insulin, insulin
resistance, or bad insulin, and oral antidiabetics can address this. Here, the
morning at 9:00 am
client has type I diabetes, meaning their body doesn't produce ANY insulin. In
the client's situation, an oral anti-diabetic agent that helps to improve how the
Central Time!
body uses insulin will serve no benefit.
140
 ANSWER KEY - ENDOCRINE
HbA1c
Page 121
<7%
Page 122 aldosterone
Daily weight B
Page 123
Avoid infection Pituitary gland
Not enough ADH
Page 124 Too much ADH
Seizures (Na < 125)
Page 125 Vasopressin B
Negative feedback Exophthalmos
Page 126
Grave’s disease Bradycardia
Levothyroxine: Low
Page 127
calcium High
Page 128 pancreas

Page 129 Autoimmune Kussmaul respirations

Page 130 Restore blood volume slow

Page 131 Avoid nephrotoxic before exercising

Page 132 dehydration potassium

direct sunlight
Page 135 long-acting insulin
cloudy insulin

Page 136 Intramuscular <70mg/dL

141
 Archer Review

N ot es
Q U E S T I O N S

D E T A I L S

DAY 3 SCHEDULE
9 AM - 4 PM CT

S U M M A R Y

K E Y T E R M S

One step closer

to becoming a
NURSE
142
 Archer Review

Part III: N ot es
Specialties Q U E S T I O N S

D E T A I L S

MATERNITY

S U P P O R T I N G W O M E N
I N P R E G N A N C Y ,
L A B O R , A N D C H I L D
B I R T H

Signs of Pregnancy GTPAL

Naegele’s Rule High Risk Pregnancy Conditions
Antepartum Testing Hyperemesis gravidarum S U M M A R Y
Blood types Preeclampsia
Glucose challenge Gestational diabetes
NST v.s. Contraction stress test Ectopic pregnancy
Fetal Heart Rates

K E Y T E R M S
“I think I’m pregnant”! “You’re probably pregnant!”

Positive signs mean the

HCP can see, hear, or
feel the baby!

143
 Archer Review

N ot es
A positive Q U E S T I O N S
pregnancy
test is what
sign of
pregnancy?
D E T A I L S

Last menstrual period

10/25/2020
Fetus in Utero
+7 days = 11/1/2020
-3 months = 8/1/2020
+1 year = 8/1/2021

Last menstrual period

7/26/2020
+7 days = 8/2/2020
S U M M A R Y
-3 months = 5/2/2020
+1 year = 5/2/2021

Antepartum Testing
Routine exams done for everyone
Blood type/Rh factor
STI testing
Glucose challenge
Urinalysis
Ultrasound
Nonstress test (NST)
Group B Strep
Kick counts

K E Y T E R M S
Blood type and Rh Factor
Important to know the mother's blood type and if they are Rh positive or
negative
If the mother is Rh negative, and the baby is Rh positive, this is considered a
‘set up’ and puts the infant at risk for erythroblastosis fetalis
Further testing needed if this is the case - after the baby is born
Direct Coombs test
Performed on the newborn's blood sample
Indirect Coombs test
Performed on the mother’s blood sample
Treatment = Rhogam

144
 Archer Review

Notes
Q U E S T I O N S

Child is Rh Red blood cells Mother makes Antibodies attack

positive; mother leak across anti-Rh Rh-positive red D E T A I L S
is Rh negative placenta antibodies blood cells in child

Glucose Challenge
Oral Glucose Tolerance Test Three Hour Glucose Tolerance Test
Done at 28 weeks Done if the 1 hour test is failed
Mother drinks 50 grams of or there are other risk factors
glucose in an oral solution It is done fasting; mothers must
1 hour later her blood sugar not eat or drink for 8 hours
is checked prior to the test
If the BG is greater than 140 A fasting sugar is checked
mg/dL, the 3 hours glucose The mother drinks 100 grams
test is performed of oral glucose
Her BG is rechecked at 1 hour,
2 hours, and 3 hours
A sugar greater than 140
S U M M A R Y
indicates gestational diabetes

Nonstress Test (NST)

This test assesses fetal well-being and oxygenation of the placenta
Evaluates if there are changes in the fetal heart rate with movement
Increase in fetal heart rate with movement = acceleration = good
Decrease in fetal heart rate with movement = deceleration = bad
This is a sign that the fetus will not tolerate labor
Results:
Reactive:
The test observed a minimum of two
accelerations of 15 beats per minute
for 15 seconds in a 20-minute period
Non-reactive:
The test did not record at least two
accelerations of 15 beats per minute
for 15 seconds in a 20-minute period
Further testing is necessary if the test results
are non-reactive K E Y T E R M S

Contraction Stress Test

Performed when the non-stress test is non-reactive
Oxytocin is administered to induce contractions and the baby is monitored to
evaluate their response to contractions
Checking to see if the baby will tolerate labor, or show signs of stress
Results
Negative
Normal - The baby did not have
decelerations in response to contractions
Positive
Bad - The baby had decelerations indicating
distress in response to contractions

145
 Archer Review

GTPAL N ot es
Q U E S T I O N S

Gravidity The number of pregnancies,

T erm Number of pregnancies
including the current one carried to term
Twins only count once! It Term - 37 weeks gestation
was ONE pregnancy! Twins only count once! D E T A I L S

P reterm A bortions L iving

Number of Children
preterm births
Number of pregnancies This is the current
These are births
ending in abortion prior number of children
between 20 and
to 19+6 weeks alive
36+6 weeks
Spontaneous Twins will count
gestation
Miscarriage twice here
Twins only count
once! Termination
If the abortion or
miscarriage was after
20 weeks gestation, it is
S U M M A R Y
included under P

Knowledge Check!
Determine the GTPAL for each client
Answers
Question 1: G5 T2 P2 A0 L3
Question 1 **Make sure to include the current
42-year-old female in her second trimester. pregnancy under G!
She has 4 previous pregnancies. Her Question 2: G4 T0 P1 A2 L2
first two children were born at 39 and 37 **Twins only count for ONE
weeks. Her third child was born at 35 gestation, but TWO living children
weeks. Her fourth child miscarried at 22 (if they’re living!)
weeks and did not survive.

K E Y T E R M S

Question 2
A 29-year-old patient with a history of 2
miscarriages at 8 and 18 weeks, twins
born at 34 weeks that are still living, and is
currently in her 3rd trimester with a
singleton pregnancy.

146
 Archer Review

High Risk N ot es
Pregnancy Conditions Q U E S T I O N S

Hyperemesis Gravidarum
D E T A I L S

What is Hyperemesis Gravidarum?

Extreme ‘morning sickness’
INTENSE, intractable,
nausea AND vomiting
during pregnancy

When to be
Concerned
Are they losing weight?
Are they dehydrated?
Skin turgor
Mucous membranes
HR S U M M A R Y
Electrolytes
Dehydration hypernatremia
Vomiting excessively hypokalemia, hypochloremia

Therapeutic Management
Dietary changes
Sit up after meals
Eat a few crackers before getting out
of bed
Small portions
No liquids with meals; drink in
between
Nothing spicy, too hot, or too cold….
Keep it simple
Medications
Promethazine
IVF
TPN/Intravenous lipids (IL)
K E Y T E R M S

Preeclampsia

What is Preeclampsia?
>20 weeks gestation
Blood pressure >140/90 mmHg
2 times
4 hrs apart
Increased BP Weight gain Proteinuria
Protein in the urine
Vision changes
Eclampsia - preeclampsia leads to seizures
Facial puffiness Pedal edema
147
 Archer Review

Notes
Q U E S T I O N S

D E T A I L S

Therapeutic Management
Delivery
Prepare for a preterm baby
Magnesium sulfate prevent seizures in mom, fetal neuroprotection
Betamethasone help develop baby’s lungs
Antihypertensives…..

Antihypertensives During Pregnancy

S U M M A R Y
YES NO

LABETALOL ACE INHIBITORS

NIFEDIPINE ARBS

HYDRALAZINE **Can cause oligohydramnios, fetal

growth restriction, and more!

Gestational Diabetes

What is Gestational Diabetes?

GDM - Gestational Diabetes Mellitus K E Y T E R M S
Diabetes diagnosed during pregnancy
Pancreas unable to deal with the increased insulin requirements of pregnancy
Increased insulin resistance secondary to hormones released during
pregnancy
Change in carbohydrate metabolism

Assessment
Screen for GDM at prenatal visits
Glucose tolerance test at 24-28 weeks
Screen for glucose in the urine

148
 Archer Review

Therapeutic
Management N ot es
Q U E S T I O N S
Control with diet and
exercise
Monitor blood glucose
Mother should not
require insulin after
delivery D E T A I L S
Neonate at risk for
Macrosomia Preeclampsia Hypoglycemia
hypoglycemia (Baby) (Mother) (Baby)

S U M M A R Y

Hypoglycemia in neonates
Fetal pancreas produces its own insulin
Fetus was used to high levels of glucose in mother’s blood
After delivery, no longer has high glucose levels, but still producing high
levels of insulin

NGN Question
The nurse is reviewing the medical record of a client who is pregnant at 35
gestational weeks
Identify the findings in the medical record that require follow up

Test Potential intervention

Non-Stress Test (NST) Nonreactive K E Y T E R M S

Contraction Stress Test (CST) Positive

Pregnancy Ultrasound Fetal HR 142 bpm

Fasting Glucose 125 mg/dL (Normal: 95 mg/dL or less)

result require follow up

Answer: The non-stress test, contraction stress test, and fasting glucose

149
 Archer Review

Ectopic Pregnancy N ot es
Q U E S T I O N S
What is an Ectopic Pregnancy?
Ectopic = out of place Ectopic pregnancy symptoms
An egg is fertilized, but implants
outside of the uterine cavity
D E T A I L S
Fallopian tube
Cervix
Abdomen

Normal Ectopic
pregnancy pregnancy

Therapeutic Management
PREVENT rupture!!
Detect with ultrasound A ruptured ectopic
Surgically removed pregnancy will go
Methotrexate to the OR STAT!
Stops the embryo from being able to grow
Aborts the fetus S U M M A R Y
Rh immune globulin
Given to mom if they are Rh negative
Prevent erythroblastosis fetalis
Don’t know Rh type of fetus
Better safe than sorry!

Fetal Heart Rate Monitoring

K E Y T E R M S

Review your on-demand

lecture for an in-depth
review of this topic!

You finished maternity!

Keep up the great work!

150
ANSWER KEY - MATERNITY
Amenorrhea
Page 143 Positive pregnancy test
HCP
Probable
5/2/2021
Page 144 Blood type/Rh factor
negative
Rhogam
28 weeks
140
Page 145
Non-reactive
Positive
morning sickness
Hypernatremia
Page 147 Sit up after meals
Promethazine
Protein in urine
Hydralazine
ARBs
Page 148
pregnancy
24-28 weeks

Page 149 hypoglycemia

out of place
Page 150 Methotrexate
Moderate variability

151
 Archer Review

N ot es
LABOR AND Q U E S T I O N S

DELIVERY
B R I N G I N G L I F E
D E T A I L S
I N T O T H E W O R L D

Obstetric Pharmacology Labor & Delivery Complications

Labor Basics Placenta Previa
Position Abruptio Placentae
Station Prolapsed Umbilical Cord
Postpartum Hemorrhage

Obstetric Pharmacology
S U M M A R Y
Tocolytic agents: slow contractions
Terbutaline
Magnesium sulfate
Oxytocic agents: stimulate contractions
Oxytocin
Misoprostol

Terbutaline
Therapeutic class: selective beta 2 adrenergic agonist
Indications: preterm labor
Action: binds to beta 2 adrenergic receptors in the respiratory system to
cause bronchodilation by inhibiting the release of hypersensitivity reaction
products from mast cells. Also works on beta 2 receptors in the uterus to
slow or stop contraction.
Nursing Considerations:
Side effects: shakiness, jitteriness, dizziness, drowsiness, sleep
disturbances, weakness, headache, nausea, vomiting, tachycardia,
hypertension, hyperglycemia. CNS overstimulation
Assess HR, BP, blood glucose K E Y T E R M S
Monitor HR of mom and baby when used in labor
Monitor fetal heart monitor strips closely
Monitor EKG

Magnesium Sulfate
Therapeutic class: electrolyte
Indications: hypomagnesemia, torsades de pointes, pre-eclampsia, preterm
labor, seizures, asthma exacerbation
Nursing Considerations:
Monitor for hypermagnesemia
Confusion, dizziness, weakness, decreased reflexes
Give IV slowly

152
 Archer Review

Oxytocin
Therapeutic class: Hormone Notes
Indications: Induction of labor; Postpartum hemorrhage Q U E S T I O N S
Action: Stimulates uterine smooth muscle causing it to contract
Nursing Considerations:
Monitor contractions
Monitor fetus
Warn mother contractions will be more painful
Monitor BP, HR, glucose, and K
D E T A I L S

Station
How far down in the birth canal the
baby is
Measured in relation to mom’s
ischial spine
Most narrow spot
Right Left At ischial spine = 0 station

Occiput Mentum (chin) Sacrum

S U M M A R Y

0 station

Anterior Posterior Transverse

Step 1:
Determine the location of the fetus in the mother's pelvis - is it on the right or
left side?
Step 2:
Identify which part of the fetus is presenting - is it the occiput (head),
mentum (chin), or sacrum (tailbone)??
Step 3:
Determine the position of the fetus relative to the mother's pelvis - is it anterior
(facing backward), posterior (facing forward), or transverse (sideways)?

Labor and Delivery

Complications
K E Y T E R M S

Placenta Previa
Placenta

Placenta is
covering the
cervix rather
Uterus than high in the
Cervix fundus
Placenta
Vagina

153
 Archer Review

Assessment
Major symptom is PAINLESS bright red bleeding
The fact that it is painless is very important
This sets it apart from an abruption Test-taking tip!
N ot es
Q U E S T I O N S
To assess the bleeding Do not do a
Pad count to determine the amount vaginal check if a
Clots client has vaginal
Color bleeding for an
Ultrasound done to confirm diagnosis unknown reason!
Ultrasound will determine type of previa
D E T A I L S

Nursing Interventions
Never ever perform a cervical exam if you suspect a placenta previa!
Would never want to irritate the placenta or uterus
Continue to monitor for blood loss
Client may have to stay on the unit to be monitored
Perform pad counts
Weigh pads
1 gram = 1 mL blood loss.
Bed rest
This may minimize blood loss
Monitor baby
If there is excessive blood loss, perfusion to the fetus can be decreased
Cesarean section indicated in most cases

Abruptio Placentae S U M M A R Y

Anatomy
Placenta
Abruptio -
placenta has
Wall of the womb
come away
from the wall
of the womb

K E Y T E R M S

Types
Causes massive amounts of painful bleeding Assessment
Two types Dark red bleeding
Incomplete Intense abdominal pain
Complete Board like abdomen (due
Incomplete is only partial separation of the to internal bleeding)
placenta Rigid uterus
Causes internal bleeding Hypotension (Think
Blood backs up behind the placenta shock due to blood loss)
Complete is when the placenta completely Maternal tachycardia
detaches Fetal bradycardia (fetal
Causes massive external bleeding distress!!)
Very painful

154
 Archer Review

Interventions N ot es
Monitor for fetal distress Q U E S T I O N S
Signs of distress? Stat c-section!
Monitor maternal bleeding
Abdominal pain
Board like abdomen
Dark red vaginal bleeding
Change in fundal height (blood in D E T A I L S
abdomen?)
Keep the BP up with IVF and/or blood
products
Prepare for delivery - most likely C-section

NCLEX Question
You are triaging a new client in the antepartum unit. They tell you that they started
bleeding this morning and were told to come in by their OB. They deny any pain or
other symptoms. Which of the following nursing interventions do you anticipate
initiating? Select all that apply.

a. Bed rest
b. Pad counts
c. Emergency vaginal delivery
d. Vaginal exam S U M M A R Y
e. Ultrasound

Answer: A, B, and E
A is correct. The nurse suspects a placenta previa based off of the clients complaint
of painless bleeding. With a placenta previa, bed rest is indicated to prevent further
bleeding. This is an appropriate nursing intervention to initiate for both the safety of
the mother and fetus and should be done right away.
B is correct. Pad counts are a way of monitoring the quantity of blood loss. Because
the nurse suspects placenta previa and the client is reporting vaginal bleeding, pad
counts are an appropriate nursing intervention to initiate. When obtaining pad
counts, they can be done in two ways. If exact quantity of blood loss is not
indicated, the nurse can just count the number of pads saturated with blood. If the
primary health care provider orders strict monitoring, the pads will be weighed to
obtain the exact number of milliliters of blood lost. When weighing pads, 1 gram is
1 milliliter of blood lost. Pad counts should be initiated for any suspected placenta
previa, so this is an appropriate nursing intervention.
E is correct. You suspect a placenta previa, and the diagnosis for this is will be
made via ultrasound, so this is an expected intervention. K E Y T E R M S
C is incorrect. An emergency vaginal delivery is contraindicated for a client with
suspected placenta previa. Because we believe that the placenta is either partially
or fully covering the cervix of this client, a cesarean section will need to be
performed. This may be distressing for some mothers, so be sure to provide
education about why this is the safest option for everyone’s health. Vaginal
deliveries with a placenta previa can cause serious harm to the mother and fetus
and are contraindicated.
D is incorrect. Vaginal exams are contraindicated for a client with a suspected
placenta previa. In this client, we suspect that the placenta is either partially or fully
covering the cervix of this client. That means that if a vaginal exam were to be
performed, the hand of the examiner would touch the placenta. We do not want to
cause this irritation and exacerbate the bleeding that is already occurring. Vaginal
exams are always contraindicated in clients with either confirmed or suspected
placenta previa.

155
 Archer Review

Prolapsed Umbilical Cord N ot es

Q U E S T I O N S

What is a Prolapsed Cord?

Umbilical cord slips through the cervix and into the vagina after rupture of
membranes and before the baby descends into the birth canal
During delivery, the prolapsed cord become compressed by the presenting D E T A I L S
part of the fetus
This cuts off oxygen to the fetus

Assessment S U M M A R Y

Cord visualized protruding through vagina What might you

Cervical exam see on the fetal
Something squishy? heart rate
Pulsing? monitor?
Mom feels something between legs

K E Y T E R M S
Nursing Interventions
Elevate the presenting part of the fetus off of the prolapsed cord
Keep your hand on the baby’s head lifting it up and call for help
Positioning
Knees-to-chest position - open the pelvis
Trendelenburg - let gravity shift the baby off the cord
Administer oxygen
Wrap cord in sterile moist towel
Emergency cesarean delivery
Key NEVER attempt to push
point!
the cord back in!

156
 Archer Review

Postpartum Hemorrhage N ot es
Q U E S T I O N S

Risk factors for Postpartum Hemorrhage

Twins or triplets
Macrosomic fetus D E T A I L S
Preeclampsia
Prolonged labor
Precipitous labor
Use of forceps or vacuum
during delivery
Placenta previa
Abruptio placenta

Assessment
Boggy uterus
This is a uterus that is not contracting to
clamp down on the blood vessels
The fundus will feel soft instead of hard as
it should S U M M A R Y
Blood loss
Pad counts - most PPH clients are
saturating pads every 15 minutes
Puddle of blood in the bed
If they try to stand up for the first time
there could be a huge gush of blood
500+ mL blood loss in 24 hours = think
post-partum hemorrhage Boggy = BAD!
Shock - if there is a large amount of blood loss
leading to hypovolemia
Decreased LOC
Pale
Diaphoretic Our client is 35 weeks
Hypotensive pregnant and reports
Tachycardic severe pain and dark
red bleeding. What
Interventions do we think is the
Fundal massage complication?
Massage the fundus - hard!
Warn the mother this will hurt, but K E Y T E R M S
you must do it to get the uterus to
contract and stop the bleeding
Every 15 minutes at a minimum What positioning can
Estimated Blood Loss (EBL) be used for a
Weigh pads to estimate the loss prolapsed cord?
1 g = 1 mL
Monitor hemoglobin and hematocrit
Medications
Oxytocin
Methylergonovine
Blood products
You finished labor and delivery!
Keep up the great work!

157
 ANSWER KEY -
LABOR & DELIVERY
Terbutaline
Page 152 Monitor EKG
decreased reflexes
Page 153 Postpartum hemorrhage
painless, bright red bleeding
1 gram = 1 mL of blood loss
Page 154
Incomplete
painful
Stat C-section
Page 155
A, B, and E
oxygen to the fetus
Page 156 Pulsing?
sterile moist towel
Macrosomic fetus
Boggy uterus
Fundal massage
Page 157
Abruptio placentae
Knees to chest or left sided
trendelenburg

158
 Archer Review

N ot es
Q U E S T I O N S

Pediatrics D E T A I L S

Newborns Pediatric disorders - ‘big

APGAR three’ systems
Complications Cardiac
Pediatric Vital Signs Respiratory
Gastrointestinal

Newborns S U M M A R Y

APGAR Assessment

Labor and Delivery K E Y T E R M S

Complications
Meconium Aspiration
Meconium is the first stool of the newborn
When the meconium is passed before delivery, the fetus is at risk for
meconium aspiration
The aspiration can occur in utero, or just after delivery when the infant takes
their first breath and starts to cry
Meconium in the lungs causes very serious illness; pneumonia, pulmonary
hypertension, and sepsis are all common
These infants become critically ill very quickly
159
 Archer Review

Assessment
If meconium aspiration is suspected, pertinent assessment will include:
Respiratory status:
Notes
Q U E S T I O N S
Accessory muscle use
Breath sounds
Grunting
Nasal flaring

Assessment to determine if meconium has been passed in utero:

D E T A I L S
Visible meconium in the fluids or on the infant
Discolored or foul smelling amniotic fluid
Discoloration of the cord
Discoloration of the nails/tongue of the infant

Interventions
Very quick action is essential to a good outcome
Suction immediately after birth - before they take their first breath
Intubation
IV antibiotics
IV fluids
Do you suction the
nose or the mouth
first?
Jaundice
S U M M A R Y
Terminology
Jaundice - elevated bilirubin level resulting in
yellowing of the sclera, skin, and mucous membranes
Bilirubin - waste product produced during breakdown
of red blood cells
Unconjugated (indirect) - The heme that is
released from hemoglobin in the process of red
blood cell breakdown is converted to
unconjugated bilirubin
Transported to the liver
Conjugated (direct) - Unconjugated bilirubin is
converted to conjugated bilirubin in the liver
Excreted in the stool

Physiological Jaundice
Jaundice that appears on day 2 or 3 of life
This is expected and not considered pathologic unless other issues arise
This is simply due to the normal transition from the placenta removing K E Y T E R M S
bilirubin to the infant's liver removing bilirubin
Followed up in outpatient setting with a pediatrician

Pathological Jaundice
Jaundice that occurs within the first 24 hours of life
Serum bilirubin will be compared to normal value based on hours of life
Jaundice appearing in the first 24 hours indicates some problem or disease
process that needs addressed
Could be an issue with the liver or an ABO incompatibility

160
 Archer Review

Kernicterus
Kernicterus is a type of brain damage that can result from high
N ot es
levels of bilirubin in the blood. Q U E S T I O N S
Complications:
Cerebral palsy
Hearing loss
Problems with vision
Problems with teeth
D E T A I L S
Intellectual disabilities
Kernicterus is completely preventable! We must monitor for
signs and symptoms of jaundice early and treat promptly.

Treatment -
Phototherapy
Helps break down bilirubin so it may be
excreted in the feces
Must ensure the eyes and genitals are
covered
Monitor the level and distance from the
light if overhead therapy being used
Double, triple, and quadruple therapy
depending on severity
S U M M A R Y

Congenital Heart
Defects
Fetal Circulation

Foramen ovale Ductus arteriosus

An opening between the right and An opening between the
left atrium present in fetal pulmonary artery and aorta
circulation
present in fetal circulation

K E Y T E R M S

161
 Archer Review

Congenital Heart Defects N ot es

Atrial Septal Defect (ASD) Coarctation of the aorta Q U E S T I O N S

Ventricular Septal Defect (VSD) Aortic stenosis

Atrioventricular canal Pulmonic stenosis

D E T A I L S
Patent Ductus Arteriosus (PDA) Transposition of the great arteries (TGA)

Tetralogy of Fallot Truncus arteriosus

Tricuspid atresia Hypoplastic Left Heart Syndrome (HLHS)

Acyanotic Heart Defects

Patent Ductus Arteriosus (PDA)

Defect
Failure of the ductus arteriosus to close
Ductus arteriosus - connects fetal S U M M A R Y
pulmonary artery to aorta
Should close 12 to 72 hours after birth
Specific assessment findings
Machine-like murmur
Treatment:
Small: often close spontaneously
Indomethacin or ibuprofen
Surgical closure
Alprostadil (Prostaglandins/PGE)
Medication that can be administered to
keep the PDA open in certain heart
defects
This allows some oxygenated blood to
get out to the body when it otherwise
couldn’t

Atrial Septal Defect (ASD)

Defect K E Y T E R M S
Opening between the atria
Shunt
Left to right = Acyanotic
History
Is often asymptomatic until later in
childhood
Child fatigues easily, DOE (dyspnea on
exertion), poor weight gain
Assessment findings:
Murmur
Treatment
Small - often close spontaneously
Large - Surgical closure

162
 Archer Review

Ventricular Septal Defect (VSD)

Defect:
N ot es
Opening between the ventricles Q U E S T I O N S
Shunt:
Left to right = Acyanotic
History:
Typical for symptoms of HF to begin at
2-8 weeks
Assessment findings D E T A I L S
Loud murmur
CHF
Treatment
CHF management: diuretics, ACE
inhibitors, β-blockers
Nutrition
Surgical closure
Bacterial endocarditis prophylaxis

Cyanotic Heart Defects

Tetralogy of Fallot
Four defects
Large VSD S U M M A R Y
Pulmonary stenosis
Right ventricular hypertrophy
Overriding aorta
History
Cyanosis
Dyspnea
Poor feeding and weight gain
Specific assessment findings
Tet spells

Tet Spells
Hypoxic spells that occur in TOF
Begins with irritability and tachypnea and followed by a prolonged period of
intense cyanosis leading to syncope
A drop in systemic vascular resistance increases the right to left shunt and
decreases pulmonary blood flow
More right to left shunting more deoxygenated blood out to the body

Management Interventions K E Y T E R M S
If mild - can go home and grow until ready for Comfort and calm
surgery Knee-to-chest
If critically ill with severe hypoxia - surgery is position
required in the neonatal period Supplemental oxygen
Ideally, complete repair around 6 months of age Sedation - morphine
Can be earlier depending on signs and Volume
symptoms
Surgery - “Tet repair”
BT shunt
Repair of pulmonary valve
Patch VSD
Bacterial endocarditis prophylaxis
What’s the priority
intervention in a tet spell?
163
 Archer Review

Obstructive Heart Defects

N ot es
Q U E S T I O N S
Coarctation of the Aorta
Defect
Narrowing of the aorta
Impedes blood flow to the lower
D E T A I L S
half of the body
History
Symptoms appear quickly
When ductus arteriosus
closes can rapidly progress to
hypotension, acidosis, shock,
and death.

Assessment
Upper extremities Lower extremities
Bounding pulses Weak or absent pulses
Hypertensive Hypotensive
Warm Pale
Pink Cool
S U M M A R Y
Management
Critical coarctation - think shock!!
Prostaglandins
Surgical repair
Lifelong follow up
High risk for recoractation or aortic aneurysm

Mixed Heart Defects

Hypoplastic Left Heart Syndrome
Defect
Left-sided structures don’t Management
develop normally Immediate treatment
Aorta is small Prostaglandins
Left atria/ventricle are Correct acidemia K E Y T E R M S
hypoplastic Inotropes
Mitral valve is atretic Plan for surgery
When the ductus arteriosus Palliative Surgery
closes, very little blood will be Norwood at birth
able to get out to the body Glenn at 2 months old
History Fontan at 2 years old
Cyanosis when DA closes Possible cardiac transplantation
Increased RR, fatigue - can lead
to obstructive cardiogenic shock
Specific assessment findings
Hepatomegaly
Murmur

164
 Archer Review

Pediatrics - Respiratory N ot es
Q U E S T I O N S

Pediatric Specific
Considerations D E T A I L S

Airway patency
Kids have a large occiput
Shoulder roll - ‘sniffing
position’
Avoid supine position
Secretions
They can’t get their own
Big head… scrunched airway!
boogers out!
Have suction ready
Swelling can occlude airway
quickly
Tongue is bigger
Airway is smaller and less
rigid
Breathing S U M M A R Y
“Kids compensate until they fall
off a cliff”
Lower lung capacity
Trend their vital signs! If they start
to look bad…. Often, they are
about to look really bad Shoulder roll opens airway

RSV and Bronchiolitis

What is Bronchiolitis?
Inflammation of the bronchioles
Bronchioles
Smallest branches of the
airway K E Y T E R M S
Lead to alveoli
Alveoli
Air sacs
Location of gas exchange
in the lungs
Thick mucus clogs up the
bronchioles
Leads to decreased gas
exchange in alveoli
Air trapping
Collapsed alveoli

165
 Archer Review

Overview
Most common in children under 2 years old
Seasonal illness
N ot es
Most common in winter Q U E S T I O N S
Causative agent usually viral
Respiratory Syncytial Virus (RSV)
Very contagious
Worst on days 4-6
D E T A I L S
Assessment
Cough Hypoxia
Fever Circumoral cyanosis
Increased work of breathing Mottling
Retractions Delayed capillary refill
Subcostal Decreased SpO₂
Intracostal Changes in behavior
Tracheal tug Irritability
Nasal flaring Lethargy
Head bobbing Poor feeding
Tachypnea
Lung sounds
Crackles
Wheezing

Interventions
Supportive treatment S U M M A R Y
Oxygenation
Nasal cannula - high flow nasal cannula
Always humidified
Fluid & Nutrition
NGT
Enteral feedings
IVF
Antipyretics
Analgesics

Croup

What is Croup?
Laryngotracheobronchitis (LTB)
Viral respiratory tract illness
Results in inflammation and edema
of the larynx and/or trachea K E Y T E R M S
Commonly affects pediatric population

Assessment
Hoarse, “bark-like” cough
Treatment
Stridor Corticosteroids
Chest wall retractions Epinephrine via nebulizer
Runny nose, fever “Racemic epi”
Symptoms often worsen at night Keep patient calm and
decrease anxiety levels
Agitation can lead to
Describe the classic respiratory distress
"croup-like" cough!
167
 Archer Review

Epiglottitis
The 4 D’s of N ot es
epiglottitis
What is Epiglottitis? Q U E S T I O N S

Inflammation of the epiglottis

Epiglottis D ysphagia
A leaf-shaped flap in the throat that
prevents food from entering the
windpipe and the lungs D ysphonia D E T A I L S
It stands open during breathing, allowing
air into the larynx
Inflammation restricts the airway D rooling
Caused by an infection
Bacterial
Haemophilus influenzae type b D istress
Medical emergency

Interventions Epiglottitis Symptoms

IV antibiotics
Humidified oxygen
Intubation and mechanical ventilation
Keep the child calm
No interventions until airway is secure
Do not irritate the throat
NO tongue depressor
S U M M A R Y
NO oral thermometer
NO assessing the throat
NPO
Tripod position
Avoid supine
Hib vaccine has reduced incidence
Encourage parents to vaccinate to prevent

NCLEX Question
The nurse is assessing a 4 year old who was sent to the ED from urgent care.
Assessment reveals tripod positioning, blue lips, mottled skin, inspiratory stridor,
and excessive drooling. Which of the following should the nurse do first?

A. Keep the child calm and call for emergency airway equipment
Vital signs B. Obtain IV access
Temp. (o) 39 C
C. Assess the throat for a cherry red epiglottis
Pulse 188 D. Place the child on high-flow nasal cannula at 100% FiO2
RR 46
SpO2 82%
Answer: A K E Y T E R M S

A is correct. Based on the presenting symptoms, the nurse suspects that this child has epiglottitis. Any
child presenting with excessive drooling, distress, and stridor is highly suspicious for this medical
emergency. In addition, this client is already showing signs of circulatory compromise including
circumoral cyanosis and mottling. The priority nursing action in this emergency is keeping the child calm
and calling for emergency airway equipment. The child is at risk of losing their airway, and airway is
always the priority!
B is incorrect. It is inappropriate to attempt to obtain IV access on a child suspected of epiglottitis before
emergency airway equipment is available. The priority action at this time is keeping the child calm and
calling for emergency airway equipment.
C is incorrect. It is inappropriate to assess the throat for a cherry red epiglottis at this time. Although
presence of a cherry red epiglottis would confirm the diagnosis of epiglottitis, this child is at risk of losing
their airway. The priority action will be to protect that airway before assessing the throat. .
D is incorrect. Placing the child on a high flow nasal cannula at 100% FiO2 is not the priority at this time.
This answer probably sounded right, because you see the O2 is 82% and they have circumoral cyanosis.
Oxygen sounds like the right answer! But this intervention addresses the ‘C’ in your ABC’s - circulation.
And the priority is always ‘A’, airway! This child is at risk of losing their airway, so all interventions need
to wait until there is emergency airway equipment close by. If anything upsets the child their airway
could spams and obstruct completely making it impossible to intubate them. That is why keeping the
child calm and calling for emergency airway equipment is the priority in epiglottitis clients. 168
 Archer Review

Pediatrics - Gastrointestinal N ot es
Q U E S T I O N S

Cleft Lip and Cleft Palate

D E T A I L S
Cleft Lip
A congenital abnormality
where there is a split, or
gap, in the upper lip on
one or both sides

Cleft Palate
A congenital abnormality
where there is a split, or
gap, in the hard palate
(the roof of the mouth)

Assessment
S U M M A R Y
Visible defect
Monitor respiratory status
Airway patency
Nutritional status
Weight gain
Hydration
Cleft palate patients
Management can be prone, cleft lip
Surgically corrected patients cannot be
Cleft lip first at 3-6 months of age prone!
Cleft palate second at 6-24 months of age
Pre-operative care The sutures should not
Monitor for aspiration be disrupted!
Assess airway patency frequently
Post-operative care
Positioning:
Position upright for feedings
Cleft palate - can be prone post op to help drain secretions
Cleft lip should NOT be prone as this could disturb the suture
K E Y T E R M S
line
Protect suture line
Elbow restraints to avoid toddler putting things in the mouth that
would compromise the sutures
No hard foods, straws, pacifiers, etc.
No oral or nasal suctioning

Feedings
Specialized bottle to facilitate a good suction/latch
Small, frequent feedings
Upright position
Burp frequently - will swallow a lot of air
May take longer to feed than other children
Monitor for aspiration
At risk for feeding to go out of their nose
169
 Archer Review

Pyloric Stenosis N ot es
Q U E S T I O N S
What is Assessment
Pyloric Vomiting
Non-bilious
Stenosis? Projectile Treatment
Right after feeding Treat dehydration D E T A I L S
Hypertrophy of the Infant is still hungry Pyloromyotomy
circular muscle fibers Dehydration Nutrition after surgery
of the pylorus, with a Malnutrition
severe narrowing of Palpable pylorus
the lumen

Omphalocele
What is an Omphalocele?
Congenital abnormality where the abdominal
contents protrude through the umbilicus while
remaining in the peritoneal sac
Occurs during weeks 9-10 of gestation
Usually diagnosed on a prenatal ultrasound S U M M A R Y

Assessment Complications
Visible defect
Dehydration
Some infants have
only the omphalocele
Some also have
cardiac defects
Lung size can be
affected Hypothermia Sepsis

Management
Pre-op Surgical
Keep exposed intestines moist
Cover with sterile gauze soaked Repair
in saline
IV fluids
IV antibiotics K E Y T E R M S
Thermoregulation

Post-op
Parenteral feeds
Trophic feeds started enterally
very gradually
Monitor weight
Very long hospital stay

Gastroschisis vs.
Omphalocele
Gastroschisis Omphalocele
170
 Archer Review

NCLEX Question
The nurse observes a parent swaddling their infant with an unrepaired
omphalocele. Which of the following statements would be appropriate?
N ot es
Q U E S T I O N S
A. "Stop! You will kill your baby."
B. "That is a nice, tight swaddle. It will help soothe your new baby."
C. "May I help you? We must be careful with the baby's intestines since we do
///not want the swaddle to push them back inside."
D. "Swaddling is not allowed for these babies; please stop."
D E T A I L S
Answer: A
C is correct. This is a therapeutic statement. It educates the parent about the need to swaddle the baby
only very loosely, and avoid any pressure on the exposed intestines so that they do not get pushed back
inside of the baby. It also promotes bonding with the infant, as it encourages the parent to touch and
care for their baby.
A is incorrect. This is inappropriate to say to a parent as it would cause panic and upset them. The
nurse wants to promote the parent bonding with their infant, and phrases like this will scare the parent
and make them afraid to touch the baby, which is not therapeutic.
B is incorrect. It is not appropriate to tightly swaddle an infant with an omphalocele. This would place
pressure on their exposed intestines and could push them back inside of the baby, which we do not
want.
D is incorrect. This is not appropriate. Swaddling is not ideal for an infant with an omphalocele due to
the exposed intestines, but if it is done loosely and avoids placing pressure on the defect it can certainly
be done. Telling the parent to stop will not promote bonding and decrease their interaction with the
baby. The nurse should educate the parent on the necessary precautions when traveling and help them
develop a positive relationship with their new baby.

S U M M A R Y
Intussusception
Occurs when one
part of the
intestine slips
inside the other
intestine
“Telescoping”
Often occurs
where the small
intestine and large
intestine meet

Assessment
Red currant jelly stools
Cyclical abdominal pain
Nausea
Vomiting K E Y T E R M S
Green, bilious emesis
Sausage-shaped mass in abdomen

Treatment Management
Enema to attempt to push the Pre-op
intestine back out Monitor stool
Air enema NPO
Hydrostatic enema IV fluids
Barium enema IV antibiotics
If unsuccessful, a surgical Post-op
repair is needed Monitor bowel function
Infection is common complication
Monitor temp, WBC, CRP
Slowly advance diet
171
 Archer Review

Hirschsprung's Disease Notes

Q U E S T I O N S
What is Hirschsprung's?
Congenital aganglionic megacolon
Absence of enteric neurons within the
myenteric and submucosal plexus of the
rectum and/or colon D E T A I L S
No neurons = No peristalsis
Stool builds up and causes a megacolon

Assessment
Delayed passage of meconium
Ribbon-like stool
Swollen belly
Vomiting, including vomiting a green or Treatment
brown substance Surgical removal of the
Constipation portion of the colon
Gas lacking innervation
Irritation Nutrition after surgery

S U M M A R Y

Key Pediatric GI Symptoms

K E Y T E R M S

You finished part 3!

Great work!
172
 ANSWER KEY - PEDIATRICS
Page 159 APGAR
Accessory muscle
Nasal flaring
take their first breath
Page 160
mouth
day 2 or 3
24 hours of life
Page 161 brain damage eyes and genitals
Page 162 Machine-like-murmur open acyanotic
acyanotic syncope 6 months of age
Page 163
Tet spells comfort and calm comfort and calm

narrowing Lower extremities Hepatomegaly

Page 164
Upper extremities aorta is small Prostaglandins

Page 165 Avoid supine position lung capacity bronchioles

4-6 Oxygenation bark-like

Page 167
Hypoxia Viral

infection calm
Page 168
Distress A
upper lip prone aspiration
Page 169
hard palate suctioning
narrowing 9-10 Thermoregulation
Page 170
Projectile Lung size Trophic feeds
C Sausage-shaped
Page 171
“Telescoping” Infection

Page 172 peristalsis Ribbon-like stool

173
 Archer Review

N ot es
MENTAL Q U E S T I O N S

HEALTH
N U R T U R I N G T H E
D E T A I L S
M I N D F O R A
H E A L T H Y L I F E

Mental Health Disorders/Pharmacology

Anxiety
Depression
Bipolar
Schizophrenia
Personality Disorders
Anorexia Nervosa
Bulimia Nervosa
Defense Mechanisms
S U M M A R Y

Anxiety
What is Anxiety?
The body’s natural response to stress

A feeling of fear, worry, and nervousness about what’s to come

Can be normal!
Concerning if it is chronic and in response to normal life activities

K E Y T E R M S

Excessive worry Fatigue Irritability

Muscle aches/soreness Restlessness Impaired concentration Difficulty sleeping

174
 Archer Review

Therapeutic Management
Address any physical symptoms
Ensure they are in a safe environment
N ot es
Reorient the client Q U E S T I O N S
Decrease stimuli
Calm environment
Monitor for self-harm
Therapeutic communication
Establish trust/rapport
Rationalize their thoughts - be logical D E T A I L S
Encourage expression of thoughts and help problem solve
Help restructure their thoughts
Determine what triggers the anxiety

Antianxiety Agents: Benzodiazepines

Onset: rapid
Short-Acting Midazolam Duration: 1-2 hours
Quick on / quick off

Onset: intermediate
Alprazolam Duration: 6-12 hours

Intermediate- Onset: intermediate

Clonazepam Duration: 18-50 hours
Acting
Onset: rapid IV, intermediate PO
Lorazepam Duration: 2-6 hours
Medium on / long off
S U M M A R Y
Onset: rapid
Long-Acting Diazepam Duration: 20-50 hours
Quick on / long off

Lorazepam
Therapeutic class: Benzodiazepine
Indications: Anxiety, sedation, seizures
Action: General CNS depression
Nursing Considerations:
Avoid alcohol
Monitor for respiratory depression
Antidote - flumazenil

Depression
What is Depression? K E Y T E R M S

“The feeling of severe despondency and dejection”

A state of low mood
Aversion to activity
Affects their thoughts, behaviors, and feelings

175
 Archer Review

Therapeutic Management
Physiological needs
Nutrition/hydration
N ot es
Sleep Q U E S T I O N S
Safe environment - assess risk for self harm
One to one observation
Remove potentially harmful items
Therapy
Express feelings
Validate their frustration and sadness D E T A I L S
Get moving!
ADLs
SSRI Adverse Effects
Antidepressants 3 S's
SSRIs
Fluoxetine
Sertraline S stomach upset
Escitalopram
TCAs
Amitriptyline
S sexual dysfunction
Nortriptyline
Protriptyline
MAOIs
S serotonin syndrome
signs & symptoms include:
Isocarboxazid hypertension, confusion, anxiety,
Phenelzine tremors, ataxia, sweating

SSRIs S U M M A R Y
Therapeutic class: Selective serotonin reuptake inhibitors
Examples: fluoxetine, sertraline, escitalopram
Indication: Depression
Action: Prevent reuptake of serotonin, thereby increasing the availability of
serotonin in the body
Nursing Considerations:
Suicide precautions important for 2-3 weeks
When the client’s mood is slowly improving, they are at increased
risk for suicide
Why? They now have the energy to follow through with a plan
Monitor for serotonin syndrome
Hypertension, confusion, anxiety, tremors, ataxia, sweating

TCAs
Therapeutic class: Tricyclic antidepressant
Examples: amitriptyline, nortriptyline, protriptyline
Indication: Depression
Action: Prevents the reuptake of norepinephrine and serotonin, thereby
increasing these neurotransmitters in the body K E Y T E R M S

176
 Archer Review

MAOIs N ot es
Therapeutic class: Monoamine oxidase inhibitors Q U E S T I O N S
Examples: isocarboxazid, phenelzine
Indication: Depression
Action: Blocks monoamine oxidase enzymes to
increase the levels of ALL neurotransmitters
(dopamine, norepinephrine, epinephrine, serotonin)
Nursing Considerations: D E T A I L S
Avoid foods high in tyramine
Side effect - hypertensive crisis

Electroconvulsive Therapy (ECT)

S U M M A R Y

Suicide Precautions

K E Y T E R M S

These medications are often used to treat

depression. They ultimately work to increase all
levels of excitatory neurotransmitters available in
the brain. Clients need to avoid wine and aged
cheeses while on these types of medications.
What medication am I? 177
 Archer Review

Case Study
The nurse cares for a 33-year-old male in the
emergency department (ED).
N ot es
Q U E S T I O N S
Client was brought to the ED by the police after he started driving erratically
and almost collided with several vehicles. After being pulled over, the client
stated he was ‘driving into this future.’ The client was incoherent in his responses
to police officers and became angry when he was arrested. He was brought to
the emergency department for medical clearance.
D E T A I L S
On exam, the client is hyperalert/hyperaroused and has an expansive affect. He
recognizes that he is in a hospital, but when asked what year it is, he states, “we
are in the future.” He states the bright lights he sees sparkle and that it is
showing him the future. He cannot detail any of his medical history or current
medications. The client does not stay on topic during the interview and
frequently switches topics. He is pacing within the exam room and insists on
going outside to the roof to see ‘if he can fly.’ The client has impaired insight
and judgment.
His father provided collateral information
and stated that his son ran out of medication Vital Signs
several days ago. He states that four days
ago, he noticed a change in his son, becoming Oral Temperature 98 ᵒ F (36.7ᵒ C)
more talkative and staying longer at work to Pulse 83/minute
feel more productive. His father states that Respirations 15/minute
his last call with his son was two days ago, Blood pressure 134/79 mm Hg
and he noticed that his symptoms had O₂ saturation 96% on room air
worsened, and he could not go to work.
S U M M A R Y

1. What key findings do you notice from the case study?

2. What do you think our client’s diagnosis would be?

and client ran out of medications. 2. Bipolar disorder

hyperalert/hyperaroused, impaired insight, impaired judgement,

ANSWER: 1. Driving erratically, states, “driving into his future”, incoherent,

Bipolar Disorder
K E Y T E R M S

What is Bipolar Disorder?

A mood disorder where there is
difficulty regulating extreme emotions.
There are periods of mania, periods of
depression, and the inability to self-
regulate these emotions.
Mania: “A mood disorder
marked by hyperactive wildly
optimistic state”
Depression: “The feeling of
severe despondency and
dejection”

178
 Archer Review

Signs of Bipolar Disorder

N ot es
Q U E S T I O N S

D E T A I L S

Is our client more consistent

with mania, hypomania, or
depression?
What medication would you
expect this client to be taking? S U M M A R Y

Lithium
Therapeutic class: Mood stabilizer
Indication: Mania
Action: Inhibits excitatory neurotransmitters such as dopamine and
glutamate, and promotes GABA-mediated neurotransmission
Nursing Considerations:
Do not administer with NSAIDs
Monitor drug levels
Therapeutic level: 0.6-1.2 mEq/L
Encourage adequate fluid intake
Side effects
Seizures, arrhythmias, fatigue, confusion, nausea, anorexia,
hypothyroidism, tremors, leukocytosis

What nursing interventions would

you consider for this client? K E Y T E R M S

Therapeutic Management
Physiological needs
Provide high-calorie finger food they can eat on the go
Safe environment
Calm, controlled, focused interactions
Don’t argue while in a manic state
Protect their privacy
Appropriate clothing
Therapeutic Communication
Set boundaries
Medications
Antipsychotics
Mood stabilizers 179
 Archer Review

Schizophrenia N ot es
Q U E S T I O N S
What is Schizophrenia?
A long-term mental disorder involving a breakdown in the relation between
thought, emotion, and behavior
There is faulty perception, inappropriate actions and feelings, withdrawal
from reality and personal relationships into fantasy and delusion, and a sense D E T A I L S
of mental fragmentation

Schizophrenia Symptoms
Delusions
“False belief firmly held Symptoms can be
to be true despite classified as
rational argument” negative or positive!
Persecution
Jealousy
Grandeur
Hallucinations
“a sensory experience of
something that does not
exist outside the mind”
Auditory
Olfactory S U M M A R Y
Tactile
Visual
Gustatory-taste

K E Y T E R M S

Therapeutic Management
Provide a safe environment
Decrease stimulation
Don’t touch them when experiencing a hallucination
Auditory hallucinations
Are they telling them to do something?
Therapeutic communication
Ask about the delusion to understand what they are experiencing
Do not argue about the delusion or hallucination
Stay focused on reality
Set limits
PRN medications
Haloperidol
180
 Archer Review

Antipsychotics
Haloperidol
Quetiapine
Olanzapine
N ot es
Q U E S T I O N S

Haloperidol
Therapeutic class: Antipsychotic
Indications: Schizophrenia, mania, aggressive behavior, agitation
Action: Inhibits the effects of dopamine D E T A I L S
Nursing Considerations:
Monitor for extrapyramidal side effects
Tardive dyskinesia
Neuroleptic malignant syndrome
Can prolong QT interval
Weekly EKG
Contraindicated in pregnancy
Routes: oral, IM, and IV

NCLEX Question
The nurse in the psychiatric unit notes that a client with paranoid schizophrenia is
yelling and blocking the television. Other psychiatric clients around him are getting
angry. What is the most appropriate action of the nurse?

a. Restrain the client

b. Escort the other clients from the day room S U M M A R Y
c. Give Haloperidol IM
d. Approach the client calmly accompanied by two other staff

Answer: D
D is correct. The first intervention is to approach the client calmly and attempt to
remove him from the day room. Staff members should not contact the agitated
client alone but should be accompanied by other personnel.
A is incorrect. Restraining the client should be the last approach for the nurse. The
first intervention should be to talk to the client to remove him from the day room.
B is incorrect. The nurse should not try to remove the other clients from the room.
The nurse should first remove the client from the place.
C is incorrect. An IM injection of haloperidol will take 30 minutes to become active.
The nurse needs to remove the client from the day room before the situation
escalates.

Personality Disorders
K E Y T E R M S

181
 Archer Review

Eating Disorders N ot es
Q U E S T I O N S
Case Study
A 22-year-old female was admitted voluntarily to the inpatient unit following a
need to “get help with her eating habits”. Reportedly, the client admits to eating
a large amount of food and feeling “disgusted” afterward, which triggers self- D E T A I L S
induced vomiting. She has done this multiple times and reports it has “gotten
out of control”. She says she is always worried about her appearance “not being
good enough”. She denies using any laxatives or diuretics; however, her mother
reports she found two empty boxes of laxatives in her apartment.

On exam, the client is alert and completely oriented. She is cooperative during
the exam and has an anxious and worried affect. She has a slender appearance
and a current body max index (BMI) of 20. Scars were observed on both index
fingers. She says physically, her only complaint is daily heartburn and occasional
dizziness during exercise.
What eating disorder do you think our client is struggling with?
How do you know?

Signs and Symptoms of Bulimia Nervosa S U M M A R Y

Signs and Symptoms of Anorexia Nervosa

K E Y T E R M S

182
 Archer Review

Assessment
N ot es
Q U E S T I O N S

D E T A I L S

What nursing interventions would you want to

consider for this client?

Therapeutic Management
S U M M A R Y

For each nursing diagnosis, specify the

appropriate nursing intervention

K E Y T E R M S

Nursing Diagnosis Potential intervention

1. Have the client fast overnight

Imbalanced nutrition 2. Provide small frequent meals
3. Allow the client to have meals alone
1. Recommend inpatient group therapy
Disturbed body image 2. Focus all conversations on the client’s weight
3. Restrict visitation with family and friends
1. Make decisions for the client
Anxiety 2. Promote positive reframing
3. Provide the client with time to be alone

183
 Archer Review

N ot es
For each nursing diagnosis, specify the
appropriate nursing intervention

Answer Q U E S T I O N S

Nursing Diagnosis Potential intervention

1. Have the client fast overnight

Imbalanced nutrition 2. Provide small frequent meals D E T A I L S
3. Allow the client to have meals alone
1. Recommend inpatient group therapy
Disturbed body image 2. Focus all conversations on the client’s weight
3. Restrict visitation with family and friends
1. Make decisions for the client
Anxiety 2. Promote positive reframing
3. Provide the client with time to be alone

NCLEX Question
A client is scheduled for hip replacement surgery. They express anxiety to the
nurse about the upcoming surgery. Which response by the nurse is most
therapeutic?
S U M M A R Y
a. “Everyone is nervous before any surgery. What you feel is completely
normal.”
b. “Here’s what’s going to happen to you during the procedure. I will explain to
you in detail.”
c. “Can you tell me what you have been told about the surgery?”
d. “Let me tell you about the care you will receive and the pain you should
anticipate after the surgery.”

Answer: C
C is correct. Open-ended questions that facilitate further discussion is most
therapeutic in this situation. This option provides the client with an opportunity to
express their thoughts further and would give the nurse a baseline of the client's
knowledge and readiness for the surgery; thus, the correct answer. This way, the
nurse can come up with appropriate explanations around what the client already
knows and by filling in facts.
A, B, and D are incorrect. These will only increase the client's level of anxiety and
are, therefore, incorrect.

K E Y T E R M S
Read
through
Study rationales
tip! out loud to
help increase
retention!

You finished mental health!

Keep up the great work!

184
 ANSWER KEY -
MENTAL HEALTH
Page 174 normal

self-harm
Page 175 flumazenil
low mood

Safe environment
TCAs
Page 176
Serotonin syndrome
Depression
hypertensive crisis
Page 177
Monoamine oxidase inhibitors
Page 178 extreme emotions
Mania
Lithium
Page 179
NSAIDs
Finger foods
Delusions
Page 180 Hallucinations
Auditory hallucinations
Tardive dyskinesia
Page 181
D

Page 182 Bulimia

Page 184 C

185
 Archer Review

Part III: N ot es
Wrap Up Q U E S T I O N S

D E T A I L S

TESTING
STRATEGIES
RECAP
Y O U R T E S T
T A K I N G T O O L K I T

You’ve built a strong knowledge S U M M A R Y

base, now it’s time to get
equipped with your tools!

The Method
1 2 3 4 5
Read the Rephrase the Are you looking Look through Choose the best
question question for true or false one answer answer and
answers? at a time move on!

Ask yourself:
Positive Is this a good
answer?
answers
True! YES - keep it
Rephrase in NO - eliminate it
Negative Don’t
your own If you don’t know
Look for answers overstress if
words, compare it to the
False! you weren’t K E Y T E R M S
keywords next option and
5 words or 100% sure
less eliminate one

Test Taking Toolkit

Opposites can’t attract Understand the
Sneaky similarities
Don’t know it? Don’t guess it
Least invasive > Most invasive
Eliminate what you know is wrong first
If part of the answer choice is wrong, the
whole answer is wrong
Do the work yourself
Listen to your client
Pain does not kill your client
This is not a priority! 186
 Archer Review

N ot es
Don’t freak out when you get a
question on a topic you don’t
know. It’s going to happen! Q U E S T I O N S

Take a deep breath

Think back to what you DO know

D E T A I L S

Remember the WHYs behind

signs and symptoms

Eliminate what you know is wrong

Get to S U M M A R Y
know the
NGN!

How to Study From Here

Attend the live course...check!
1 Live Review
Review OnDemand videos to master
concepts
Use the Archer Qbank with 2900+
2 Practice questions
NCLEX Questions
Learn from each question with detailed
answer rationales K E Y T E R M S

Identify the areas you need more study

on, and go back to those videos!

Launch as many readiness assessments

3 Assess your readiness
as you would like
Achieve a score greater than the
‘Average Peer Score’ predictor 4 times -
you are ready!

4 PASS YOUR NCLEX!

187
 Archer Review

N ot es
Q U E S T I O N S

MOCK
NCLEX D E T A I L S

You got this!

Question 1
The emergency department (ED) nurse triages a client with suspected bacterial
meningitis. The nurse plans on assessing the client for Kernig's sign. The nurse
understands that this sign is positive when the client
a. reports pain when the knee is extended and the hip flexed.
b. has a stiff neck when the neck is flexed towards the chest.
c. forearm spasms when a blood pressure cuff is inflated on the upper arm. S U M M A R Y
d. reports pain in the calf when the foot is dorsiflexed.

Question 2
Which of the following is most consistent with a client who has hypothyroidism?
a. Thin, anxious-appearing female with exophthalmos with rapid pulse and
complaints of diarrhea
b. Slightly obese, perspiring female who complains of feeling cold all the time
and frequent diarrhea
c. Thin, perspiring male with a hoarse voice, facial edema, and a thick tongue
with complaints of diarrhea
d. Slightly obese female with periorbital edema who complains of cold
intolerance, brittle hair, and dry skin

Question 3
A nurse is reviewing a client's arterial blood gas
results and notes the following: pH 7.45, PCO2 of
30 mm Hg, and HCO3 of 22 mEq/L. Which of the
following conditions do these results indicate?
a. Metabolic acidosis, compensated K E Y T E R M S
b. Respiratory alkalosis, compensated
c. Metabolic alkalosis, uncompensated
d. Respiratory acidosis, uncompensated

Question 4
The nurse is caring for a client with a suspected pulmonary embolism. After the
nurse notifies the rapid response team, the nurse should perform which action?
Select all that apply.

a. place the client in a left lateral trendelenburg position

b. obtain vital signs
c. obtain a prescription for warfarin
d. place the client in the high-Fowler’s position
e. obtain an order for a chest radiograph (x-ray)
188
 Archer Review

Question 5
The nurse working in the clinic reviews laboratory data for a client prescribed
N ot es
lithium. Highlight the findings in the laboratory data that requires follow-up. Q U E S T I O N S

D E T A I L S

Question 6
The infant just finished surgery for the repair of a malfunctioning
ventriculoperitoneal shunt. Which symptom would indicate to the nurse that a
problem could be arising?
a. Increased urine output
b. Depressed fontanelles
c. Decreased heart rate
d. Irritability
Question 7 S U M M A R Y
The nurse is teaching a client about newly prescribed insulin glargine. The nurse
recognizes the need for further instruction when the client makes the following
statement? Select all that apply.
a. "I will take this insulin right before my meals."
b. "I should roll this vial of insulin before removing it with the syringe."
c. "This insulin will help control my glucose for 24 hours."
d. "I can only inject this insulin into my abdomen."
e. "I'm glad to know I can mix this with my regular insulin.”

Question 8
A nurse is conducting client teaching on a client receiving a monoamine oxidase
inhibitor (MAOI) about his drug therapy. The client has demonstrated
understanding by stating, “I should avoid tyramine-containing foods, or I may go
into a hypertensive crisis.” When asked to list specific tyramine-containing foods,
the client would be correct by including which food?
a. Cream cheese
b. Swiss cheese
c. Milk
d. Ice cream
K E Y T E R M S
Question 9
The nurse is caring for a group of clients. Which client should the nurse see first?
Place the clients in order based on the priority that the nurse should see them.
a. A 65-year-old newly admitted client with acute coronary syndrome
(ACS) who is receiving a heparin infusion.
b. A 51-year-old client who has a discharge prescription following a heart
failure exacerbation and has questions.
c. A 46-year-old client two days post-operative from a vaginal
hysterectomy reporting burning at the indwelling catheter site.
d. A 31-year-old client three days post-operative who requires a sterile
dressing change.

189
 Archer Review

Question 10
The nurse in the medical-surgical unit is caring for a 59-year-old female N ot es
Nurses Note: Health History: Q U E S T I O N S
0845: Morning capillary blood glucose obtained of Diabetes mellitus, type I
189 mg/dL (10.4 mmol/L). 4 units of lispro insulin Hyperlipidemia
administered per sliding scale. Vancomycin Pericarditis
infusion started at this time in left peripheral Asthma
vascular access device that was patent with
Orders:
positive blood return. Call bell placed within reach. 0700: D E T A I L S
0950: The client alerted RN that they 'didn't feel Admit to medical/surgical
good.' The client appeared pale, diaphoretic, and for cellulitis
lethargic. The client's words became slurred, and vancomycin 1 g, IV, every
she was disoriented, asking, "where am I?" 'The 12 hours
client's breakfast tray appeared untouched. The Resume all home
client's capillary blood glucose was obtained at 41 medications
Insulin lispro, sliding scale,
mg/dL (2.2 mmol/L). Glasgow coma scale: 13. Vital before meals
signs: T 98° F (36.7° C), P 108, RR 22, BP 150/86, Consistent carbohydrate
pulse oximetry reading 95%. A rapid response was diet
called because of the client's condition change. Daily labs: complete blood
1000: Rapid response team arrived at the bedside. count and comprehensive
Report was given to the rapid response nurse. metabolic panel

Action to Take Parameters to Monitor

Potential Condition
Action to Take Parameters to Monitor
S U M M A R Y
Action to Take Potential Condition Parameters to Monitor

Keep client NPO until

mental status Cerebrovascular
Creatinine
improves accident
Glasgow coma scale
Administer glucagon 1 Diabetic Ketoacidosis
Capillary blood
mg IM Hypoglycemia
glucose
Have the client drink 8 Vancomycin infusion
oz of skim milk Urinary ketones
reaction
Stop the vancomycin

Question 11
The nurse is caring for a client newly admitted to the medical-surgical unit.
Nurse’s Note Primary Healthcare Provider
2100 –A 17-year-old female was admitted with (PHCP) Prescriptions
severe dehydration. The client was at school and
- 0.9% saline at 150 mL/hr
‘blacked out.’ The client is underweight and
- Psychiatry consultation K E Y T E R M S
appears malnourished. She was diagnosed with
- Fluoxetine 40 mg PO daily
anorexia nervosa two years ago. She endorsed
- Daily weights
suicidal ideations saying, ‘She is tired of her body
- Dietician consultation
and wants to end it all.’ She reports persistent
- Supervise mealtimes
dizziness and a headache.

Select one (1) prescription and one (1) nurse’s note finding to complete the sentence.
Based on the client’s clinical data, the nurse should immediately _______________
based on the client’s _________________.
PHCP’s Prescriptions Health History Findings

administer olanzapine suicidal ideations

initiate 0.9% saline infusion severe dehydration
weigh the client altered nutrition
establish a therapeutic rapport underweight appearance
190
 Archer Review

Question 12
A 78-year-old man is admitted with sepsis. Which of the following should the N ot es
nurse expect the health care provider to order? Select all that apply.
Q U E S T I O N S
a. Crystalloids
b. Blood cultures
c. Abdominal x-ray
d. Antibiotics
e. Two large-bore IVs
f. Vasopressors if shock persists
D E T A I L S

Question 13
The nurse is caring for a client with the following tracing on the electrocardiogram.
When reviewing the client’s medical history, which condition could be causing this
dysrhythmia?

a. Graves' disease
b. Increased intracranial pressure
c. Severe hypothermia
d. Myxedema coma
S U M M A R Y

Question 14
The nurse is caring for a client experiencing variable decelerations. The nurse
observes the umbilical cord protruding through the vagina. Place the priority actions
in the correct order.
a. Place the client in the Trendelenburg position
b. Prepare for delivery
c. Apply pressure to lift the presenting fetal part
d. Administer oxygen
e. Stay with the client and call for help

Question 15
A 3-month-old infant is in the emergency room for acute abdominal pain. The nurse
suspects intussusception. Which assessment data would further support the
nurse’s suspicion?
a. Black tarry stool
b. Ribbon-like stool
c. Red, currant jelly-like stool K E Y T E R M S
d. Frothy, foul-smelling stool

Master the basics before tackling

the complex—solidifying your
foundation will make the next
challenge that much stronger.

191
 Archer Review

NGN Unfolding Case Study

The nurse at the outpatient clinic is caring for a 20-year-old female.
N ot es
Q U E S T I O N S

Outpatient Clinic Nurse’s Notes

1030: A 20-year-old female and her mother present to the clinic reporting a 3-
day fever and diarrhea with nausea and vomiting (N/V). She has been unable to
eat and has tolerated only sips of fluid. Because she has been unable to eat, D E T A I L S
she has not taken her insulin. Her mother stated, "I thought she was getting
better, but it happened so suddenly that she started feeling like this." Her
mother reports she recently arrived back from an international trip. On
assessment, the client is weak and has to be assisted to the examination table.
She is very lethargic and is slow to respond to any question. She has
tachypnea, and respirations are deep and rapid with an acetone-type of odor.
Lung sounds are clear bilaterally. Hypoactive bowel sounds in all quadrants,
and the client reports nausea. Skin is warm and very dry. Capillary refill > 3
seconds. Peripheral pulses are thready. The client keeps saying, "I'm thirsty: I
am thirsty." She endorses a headache 6 on a scale of 0 (no pain) to 10 (severe
pain). She reports dizziness. Vital signs: T 102° F (39° C), P 126, RR 26, BP
96/66, pulse oximetry reading 97% on room air. Capillary blood glucose was
obtained at 374 mg/dL (normal 70-110 mg/dL).

Medical History Order from Heath Care Provider

S U M M A R Y
Diabetes mellitus, type I Direct admission to the intensive
Borderline personality disorder care unit (ICU) immediately via
Multiple suicide attempts EMS
Major depressive disorder Establish peripheral vascular
Acne vulgaris access devices
Two liters of 0.9% saline to run
concurrently over one hour
ICU Nursing Notes Ondansetron 4 mg intramuscular
(IM) every six hours PRN nausea
and vomiting
1145: Client arrives at ICU and is
Acetaminophen 1 gram every
severely lethargic. Physician orders
eight hours PRN pain
reviewed. Vital signs: T 102° F (39°
5 units of regular insulin
C), P 136, RR 29, BP 92/60, pulse
intravenous (IV) push x 1 dose
oximetry reading 96% on room air.
CBC with differential
Peripheral pulses were thready.
Complete metabolic panel (CMP)
Capillary blood glucose was
Blood cultures × 2 sites
obtained at 379 mg/dL (normal 70-
Arterial blood gas on room air
110 mg/dL). The client had one
Obtain glycated hemoglobin A1C
episode of emesis of opaque fluid
level
upon arrival. Reports nausea. K E Y T E R M S
NPO
1250: Intravenous fluids Consult endocrinology reason:
administered. Vital signs: T 100° F DKA management
(37.8° C), P 113, RR 29, BP 101/70,
pulse oximetry reading 96% on
room air. Peripheral pulses were 1 Which of the following three (3)
thready. Capillary blood glucose assessment findings requires
was obtained at 360 mg/dL immediate follow-up?
(normal 70-110 mg/dL). Headache a. lung sounds
was reported as 8 on a scale of 0 b. reports of dizziness
(no pain) to 10 (severe pain). c. previous suicide attempts
Reports nausea. The endocrinology d. pulse, respirations, blood pressure
consult was notified, and regular e. abdominal assessment finding
insulin was administered as f. pulse oximetry reading
prescribed. g. capillary blood glucose result
192
 Archer Review

NGN Unfolding Case Study Continued

The nurse at the outpatient clinic is caring for a 20-year-old female.
Notes
Q U E S T I O N S
2 For each client finding below, click to specify if the finding is consistent
with the disease process of diabetic ketoacidosis (DKA) or hyperglycemic-
hyperosmolar state (HHS). Each finding may support more than 1 disease
process.
D E T A I L S
Hyperglycemic Diabetic Ketoacidosis
Client Findings
Hyperosmolar State (HHS) (DKA)

Hyperglycemia

Fluid volume deficit

Urine Ketones

Abrupt onset of symptoms

Altered level of
consciousness

3 Complete the sentence below by choosing from the list of options.

The client is at highest risk of developing suicide

S U M M A R Y
diabetic ketoacidosis

hyperglycemic hyperosmolar state

as evidenced by the client’s history of suicide attempts.

recent international travel.

fluid volume deficit.

The outpatient clinic nurse gives the intensive care unit nurse a telephone handoff
report.
The client arrives at the ICU, and the ICU nurse reviews the nurses' notes, medical
history, and physician orders.

4 Complete the sentences below from the list of options

The nurse understands that the rationale increase urinary output.

for the prescribed intravenous fluids is to K E Y T E R M S
lower blood glucose.

restore circulatory volume.

The nurse understands that rapidly drop the blood glucose.

the rationale for the prescribed
intravenous regular insulin is to treat the ketoacidosis.

restore circulatory volume.

193
 Archer Review

NGN Unfolding Case Study Continued

The intensive care unit (ICU) nurse obtains vital signs, reviews the physician's
N ot es
orders, and makes an entry into the nurses' note. Q U E S T I O N S

5 It would be a priority for the nurse to implement which two (2) physician
orders based on the 1145 nursing note entry?

A. Establish peripheral vascular

D E T A I L S
///access devices
B. Two liters of 0.9% saline to ICU Nursing Notes
///run concurrently over one hour
C. Ondansetron 4 mg 1145: Client arrives at ICU and is
///intramuscular (IM) every six severely lethargic. Physician orders
///hours PRN nausea and vomiting reviewed. Vital signs: T 102° F (39° C),
D. Acetaminophen 1 gram every P 136, RR 29, BP 92/60, pulse oximetry
///eight hours PRN pain reading 96% on room air. Peripheral
E. 5 units of regular insulin pulses were thready. Capillary blood
///intravenous (IV) push x 1 dose glucose was obtained at 379 mg/dL
F. Obtain laboratory testing (normal 70-110 mg/dL). The client had
G. Consult endocrinology one episode of emesis of opaque fluid
H. Educate the client that they are upon arrival. Reports nausea.
///NPO
1250: Intravenous fluids administered.
Vital signs: T 100° F (37.8° C), P 113, RR
The nurse reviews the nurses' note
29, BP 101/70, pulse oximetry reading
entries from 1250 (ICU Nurses' 96% on room air. Peripheral pulses were
Notes (2)) and compares them to the thready. Capillary blood glucose was
S U M M A R Y
1030 entry (clinic nurses' notes). obtained at 360 mg/dL (normal 70-110
mg/dL). Headache was reported as 8 on
6 For each assessment finding, a scale of 0 (no pain) to 10 (severe pain).
determine if it is improved, Reports nausea. The endocrinology
unchanged, or worsening consult was notified, and regular insulin
was administered as prescribed.
Note: Each row must have 1
response option selected.

Assessment finding Improved Unchanged Worsening

Pulse rate

Blood pressure

Capillary blood
glucose

Pain level

Reports of nausea K E Y T E R M S

Peripheral pulses

You’ve made incredible

progress on your path to
becoming the outstanding
nurse you’re meant to be.

Keep this momentum and

before you know it, you will be
using your knowledge and
compassion to save lives!

194
 Mock NCLEX
Score Sheet

Question Correct Incorrect Question Correct Incorrect

1 12

2 13

3 14

4 15

5 Unfolding Case Study

6 1

7 2

8 3

9 4

10 5

11 6

You got this future nurses!

Total correct: __ Goal: 80-100%

Total omitted: __ Doing better! 60-80%

Total incorrect: __ Need some more work - I can get there! 0-60%

For nursing or tutor-related questions,

please email:
nclextutors@archerreview.com.

YOU DID IT!!!

 Archer Review

Mock NCLEX Answer Key N ot es

Q U E S T I O N S
Answer 1: A
Choice A is correct. Kernig's sign is positive if pain occurs upon extension of the
knee. When meninges are inflamed (meningitis), movement of the spinal cord or
nerves against the inflamed meninges results in pain. With the client placed supine
and hip flexed at 90 degrees, an extension of the knee stretches the hamstring and
triggers pain by pulling tissues surrounding an inflamed spinal canal and meninges.
Choice B is incorrect. Brudzinski's is positive when severe neck stiffness occurs after D E T A I L S
the neck is flexed towards the chest, causing the client's hips and knees to flex.
Brudzinski's sign is also a sign of meningeal irritation/inflammation.
Choice C is incorrect. The appearance of a carpopedal spasm (flexion of the wrist,
thumb, and metacarpophalangeal joints along with hyperextension of the
interphalangeal joints) is referred to as Trousseau's sign. Such carpopedal spasms
result from ischemia secondary to compression by the inflated sphygmomanometer
cuff on a client's arm. Trousseau's sign signifies latent tetany; this is seen in
hypocalcemia and hypomagnesemia. A positive Trousseau helps the clinician to
detect the early presentation of hypocalcemia.
Choice D is incorrect. When a client experiences pain in the calf upon sharp
dorsiflexion of the foot with the knee extended, it refers to a Homan's sign. A
positive Homan indicates that the client may have a deep vein thrombosis (DVT).
However, Homan's is unreliable for diagnosing DVT and must be used with
diagnostic imaging and other physical assessment findings (Well's score).

Answer 2: D
D is correct. The patient with hypothyroidism would demonstrate clinical signs and
symptoms of a low metabolic rate resulting from the depletion of circulating thyroid
hormone. S U M M A R Y
A is incorrect. Exophthalmos may occur when hyperthyroidism is present.
B is incorrect. The patient is not likely to perspire, as lower than normal body
temperature is usually present.
C is incorrect. Constipation is a likely complaint among those with hypothyroidism.

Answer 3: B
The normal pH ranges between 7.35-7.45. As seen in this case, a respiratory
condition would show an inverse relationship between the PCO2 and the pH. In a
metabolic state, the HCO3- would have direct contact with the pH. Because the pH
is at 7.45, which is within the normal range, this is an indication that compensation
has occurred. Therefore, option B is the correct answer, while options A, C, and D
are incorrect.

Answer 4: B and D
Choice B and D are correct. The nurse needs to obtain vital signs because a client with a
suspected pulmonary embolism may experience hypoxia, tachypnea, and tachycardia.
The nurse can intervene by providing supplemental oxygen if the vital signs show
hypoxia. The client should be placed in a high Fowler's position. This allows full chest
expansion, which may optimize the client's oxygen saturation.
Choice A is incorrect. For a client with a suspected air embolism, they should be placed
in a left lateral Trendelenburg position. This position encourages the air bubble to move K E Y T E R M S
out of the right ventricular outflow tract (RVOT) and into the right atrium, where it can be
trapped and reabsorbed. If this does not work, the client may need immediate treatment
via interventional radiology. 100% oxygen administration will also help reduce the air
bubble's size and prevent organ ischemia. This client has a pulmonary embolism and
needs to be in a high Fowler's position.
Choice C is incorrect. The nurse does not need to obtain a prescription for warfarin.
Warfarin takes 3-5 days to establish efficacy. The client needs immediate treatment,
such as anticoagulants, thrombolytics, or interventional radiology. Warfarin may be used
to prevent future PE, but would not be efficacious in treating a current PE.
Choice E is incorrect. A chest radiograph is not used to diagnose a pulmonary embolism.
This test would be unable to visualize the embolism. A CT angiogram of the chest is used
to diagnose a PE.

196
 Archer Review

Answer 5: Sodium, BUN, Lithium level

The findings requiring follow-up include the decreased sodium level, which is concerning
because hyponatremia facilitates lithium toxicity. The elevated BUN requires follow-up
N ot es
because this is further evidence of dehydration. The lithium level is elevated, which is Q U E S T I O N S
quite concerning for toxicity. The white blood cell (WBC) count is elevated, but this is not
a concern. Lithium causes leukocytosis, which is a benign side effect. While this could
mask acute infection and inflammation, this is an expected finding. Additional
information: Lithium is a salt and is utilized to treat bipolar disorder. Key teaching points
for a patient taking lithium include the avoidance of dehydration, adhering to the dosing
schedule to maintain a therapeutic level of 0.6-1.2 mEq/L, and reporting signs of toxicity D E T A I L S
such as nausea, vomiting, and ataxia. The patient should be instructed that the drug level
should be obtained twelve hours after the last dose.

Answer 6: D
D is correct. Irritability in an infant is a sign of increased intracranial pressure.
A is incorrect. Increased urine output is not related to problems with VP shunting.
B is incorrect. Depressed fontanels are a sign that the VP shunt is draining the CSF from
the child’s cranial cavity. A bulging fontanel is a sign of a problem.
C is incorrect. Bradycardia is not an initial sign of increased ICP. Tachycardia should be
observed with increased intracranial pressure. S U M M A R Y

Answer 7: A, B, D, and E
Choices A, B, D, and E are correct. These statements are incorrect and require follow-up.
Insulin glargine is a long-acting insulin that has no peak effect. Thus, it is not taken with
meals. It is dosed once a day to provide glucose control for 24 hours. Insulin glargine is
not a suspension; thus, it does not need to be rolled like NPH. This insulin is not mixed
with any other insulin. Insulin glargine does not have only to be injected into the
abdomen.
Choice C is incorrect. This statement is factual and does not require additional teaching.
Insulin glargine provides basal glucose control for up to 24 hours. Combined with a
carbohydrate-controlled diet, this should decrease the client's reliance on correctional
insulin.
Answer 8: B
Fermented, aged, or smoked foods are high in tyramine and should be avoided; thus,
Swiss cheese. Cream cheese, milk, and ice cream are unfermented milk products and may
be taken by patients on MAOIs without incident. The correct answer, therefore, is option
B. Options A, C, and D are incorrect.

Answer 9: A, C, D, B
A 65-year-old newly admitted client with acute coronary syndrome (ACS) who is
receiving a heparin infusion. K E Y T E R M S

A 46-year-old client two days post-operative from a vaginal hysterectomy reporting

burning at the indwelling catheter site.
A 31-year-old client three days post-operative who requires a sterile dressing change.
A 51-year-old client who has a discharge prescription following a heart failure
exacerbation and has questions.
The nurse should first attend to the client with acute coronary syndrome (ACS) on a
heparin drip due to the life-threatening nature of ACS and the need for close
monitoring of the infusion and potential bleeding. Next, the nurse should check on
the client experiencing burning at the urinary catheter site, two days post-
operation, as it may suggest an infection or catheter issue, though it's less urgent
than ACS management. The third priority is the client needing a sterile dressing
change three days post-operation, important but less urgent. Lastly, the client
ready for discharge teaching should be seen, as their need is educational and they
are stable, making it the lowest priority.
197
 Archer Review

Answer 10:
Keep the client NPO
until mental status Glasgow coma scale
N ot es
improves Q U E S T I O N S
Hypoglycemia
Administer glucagon 1
Capillary blood glucose
mg IM

The client has hypoglycemia due to insulin and not eating. They need glucagon to raise D E T A I L S
their low blood sugar. The client shouldn't eat due to risk of choking from lethargy and
slurred speech. Instead, monitor their blood sugar after glucagon and check their
consciousness level, noting an initial Glasgow coma scale of 13 out of 15. Vancomycin
treatment is unrelated to the current condition, but watch for 'red man syndrome,' a
possible reaction. Diabetic ketoacidosis isn't likely because the client's sugar is low, not
high. Though symptoms resemble a stroke, the issue is hypoglycemia, not stroke or
vancomycin-related. Monitor creatinine levels during vancomycin treatment.

Answer 11: Initiate 0.9% Saline; severe

dehydration
Based on the client’s clinical data, the nurse should immediately initiate a 0.9% saline
infusion based on the client’s severe dehydration. The client is exhibiting concerning
signs of severe dehydration (persistent dizziness and an episode of syncope). The nurse
must prioritize physical needs and interventions, which is initiating intravenous fluids.
The intravenous fluids will positively affect severe dehydration. The nurse should then
address the client’s suicidal ideations by ensuring the environment is safe and then
establishing a therapeutic rapport. While no approved medication is available for S U M M A R Y
anorexia, olanzapine has shown some benefits as it increases weight. This medication
will take several days to gain efficacy and is not the priority. Weighing the client will not
correct the client’s severe dehydration, which is causing her dizziness and syncope.
Physical needs are still a priority if a client has a mental health disorder

Answer 12: A, B, D, E, and F

Choices A, B, D, E, and F are correct. When treating sepsis, inserting intravenous access
(2 large-bore IVs, 16-gauge), obtaining blood cultures, and starting crystalloid fluids are
critical initial interventions. Vasopressors are administered if the shock persists despite
the initial interventions and aggressive fluid resuscitation.
Intravenous access: When sepsis is suspected, adequate venous access with two large-
bore IVs (16-gauge) (Choice E) must be placed as soon as possible. This allows for the
administration of aggressive volume resuscitation (crystalloids) and broad-spectrum
antibiotics.
Answer 13: A
Choice A is correct. This tracing reflects sinus tachycardia (ST). ST can be caused by an
array of conditions such as dehydration, hypo- and hyperglycemia, stress, anxiety, and
thyroid conditions such as hyperthyroidism. Graves’ disease is the most common cause of
hyperthyroidism, and this increased metabolic and sympathetic activity would cause
tachycardia.
Choices B, C, and D are incorrect. Increased intracranial pressure would manifest with K E Y T E R M S
bradycardia. Hypothermia causes a slowing of metabolic and sympathetic activity; thus,
bradycardia is a feature of this condition. Myxedema coma is an endocrine emergency
marked by severe hypothyroidism. The hallmark of severe hypothyroidism is life-
threatening bradycardia.

Answer 14: C, E, A, D, B
The priority nursing action is to apply pressure to the presenting fetal part. This will lift
the fetus off the prolapsed umbilical cord and restore blood flow to the fetus. The nurse
cannot let go until the health care provider arrives to deliver the fetus. The nurse should
stay with the client and call for help. This is a medical emergency, and the nurse must
remain with the client to ensure safety. Next, the nurse needs someone to place the client
in Trendelenburg’s position. This will assist with keeping the presenting fetal part off of
the umbilical cord, so that blood flow to the fetus continues. Next, the nurse needs
someone to administer oxygen to the mother via a simple face mask at 8-10 L/min. This
will optimize oxygenation to the fetus. Lastly, the nurse needs to prepare for the
immediate delivery of the fetus. This is the only way to resolve this medical emergency. 198
 Archer Review

Answer 15: C
Choice C is correct. Red, currant jelly-like stools are characteristic of intussusception.
Choice A is incorrect. Black, tarry stools indicate upper GI bleeding in a patient. Choice B
Notes
is incorrect. Ribbon-like stools are characteristic of Hirschsprung’s disease. Choice D is Q U E S T I O N S
incorrect. Frothy, foul-smelling stools are a characteristic stool pattern for cystic fibrosis.

NGN Case Study Answers

D E T A I L S
1
Answer: B, D, & G
The client's dizziness, pulse, respirations, and blood pressure require follow-up. The
dizziness suggests hypovolemia, supported by the thready peripheral pulses and
capillary refill > 3 seconds. The pulse is high, and blood pressure is low, supporting the
diagnosis of dehydration. The high respiratory rate, combined with hyperglycemia,
strongly suggests diabetic ketoacidosis. The DKA diagnosis is likely because the client
reports an illness that raises blood glucose, making DKA a likely complication if the sick
day rules are not followed. The sick days were not followed because the client reports
not taking her insulin which should be taken during illness.
The lung sounds being clear is not of concern. The client's previous suicide attempts are
not of concern because the current illness does not suggest self-harm. The abdominal
assessment is insignificant because the client has had nausea for some time, and the
hypovolemia is the most significant concern.

2 Hyperglycemic
Diabetic Ketoacidosis
Client Findings Hyperosmolar State
(DKA) S U M M A R Y
(HHS)

Hyperglycemia

Fluid volume deficit

Urine Ketones

Abrupt onset of symptoms

Altered level of
consciousness

This client has an abrupt onset of DKA symptoms, acetone type of breath, fluid
volume deficit (tachycardia, dry skin, thready pulses), and altered level of
consciousness, which suggest and coincide with diabetic ketoacidosis.
The significant dehydration in DKA and HHS explains the altered LOC. The acidosis
in DKA causes the client to experience hyperkalemia, requiring the nurse to
implement continuous cardiac monitoring.
The condition the client is experiencing is likely because DKA occurs with type I
diabetes mellitus, whereas type II diabetes mellitus may adversely occur with HHS.
HHS has a more gradual onset of symptoms that is driven by dehydration. Ketones in
K E Y T E R M S
the blood and urine is not a finding associated with HHS.

3 Answer: diabetic ketoacidosis, fluid

volume deficit.
The client is at the highest risk for DKA, as evidenced by the client's tachypnea,
hyperglycemia, fluid volume deficit, lethargy, and history of type I diabetes mellitus. A
client with type II diabetes mellitus is unlikely to experience DKA because they have
enough insulin to prevent ketosis. The client's international travel has no relevance
except that is where she may have gotten the initial gastrointestinal infection. The client
has not voiced or has any manifestations of self-injury, and thus, suicidality is not a
problem at this time.

199
 Archer Review

Answer: restore circulatory volume, Notes

4

treat the ketoacidosis. Q U E S T I O N S

The treatment of DKA involves two modalities - intravenous fluid and regular insulin.
DKA occurs because a lack of insulin causes the body’s increase in metabolism in a less
efficient attempt to use other energy sources. The result is the burning of lipids from fat
stores. Ketones are formed due to lipolysis, and metabolic acids are produced. Serum
osmolality increases slightly, drawing fluid and sodium from cells, resulting in
dehydration and increased urinary output. Blood lactate levels rise, further contributing D E T A I L S
to acidosis. The most common causes are underlying infection, disruption of insulin
treatment, and new or initial-onset DM.
The treatment goal for the isotonic saline bolus is to rehydrate the client and restore
circulatory volume. This will also lower blood glucose but emphasizes treating
hypovolemia. Increasing UOP would be unhelpful because this would cause further
dehydration. The client with DKA has polyuria which primarily causes dehydration.
The treatment goal for regular insulin is to stop the ketoacidosis and allow insulin into
the cell, allowing carbohydrates to be the fuel source - not fats. The treatment goal is to
lower the blood glucose by 50-75 mg/dL/hr. A rapid decrease in blood glucose could
cause life-threatening hypoglycemia and an osmotic fluid shift.

5
Answer: A & B
The nurse should immediately implement two orders: establishing the peripheral
vascular access device and administering intravenous fluids. The client's blood pressure
has declined, and the pulse has increased, which indicates that the client's clinical status
is declining. Using the airway, breathing, and circulation principle, the nurse must address
the client's circulatory decline by administering isotonic fluids. Correcting the glucose S U M M A R Y
levels via regular insulin can wait because while their glucose has increased, their decline
in blood pressure is concerning. The other orders can wait until the client's condition
stabilizes. The priority treatment in DKA is restoring fluid volume status and normalizing
blood glucose levels.

6 Assessment finding Improved Unchanged Worsening

Pulse rate

Blood pressure

Capillary blood
glucose

Pain level

Reports of nausea

Peripheral pulses

K E Y T E R M S

Although the client's vital signs are not within desired limits, the two liters of isotonic
saline have improved the client's volume status.
Compared to the client's vital signs at the outpatient clinic, the pulse rate has
decreased, and the blood pressure has increased. This is an objective clinical
improvement. It would be wise for the nurse to contact the physician for further
hydration orders.
Isotonic saline rehydration also showed a minor improvement in the client's capillary
blood glucose compared to baseline.
The client's headache pain is worsening, and the report of nausea is unchanged
compared to the admission assessment.
The peripheral pulses being thready is also unchanged, further supporting the need
for the nurse to get further orders for hydration.

200
 NEXT
STEPS
AFTER THE LIVE
REVIEW
 Archer Review

Congratulations, You've Made It Through the Live Review!

Amazing job! Your dedication and hard work have brought you to this point in your
journey toward preparing for the NCLEX exam. Now, it's time to set your sights on
the next steps. To ensure that you're fully prepared, you have the option of choosing
between two study plans: the 6-week intensive plan and the 12-week plan designed
for individuals with full-time work or other significant time commitments.

Option 1: The 6-Week Plan

If you have the time and energy to commit to a more intensive study schedule, the
6-week plan might be the perfect fit for you. This plan will require your full focus and
dedication, but it will prepare you thoroughly for the NCLEX exam in a shorter
timeframe.

Option 2: The 12-Week Plan

For those who work full-time or have multiple time commitments, the 12-week plan
offers a more flexible and manageable approach. It allows you to balance your
studies with your daily life and ensures you have sufficient time to cover all
necessary material thoroughly.

Regardless of the plan you choose, remember that consistency is key. Each day,
make sure to include questions from all subjects and lessons. Some days might be
challenging, and that's perfectly normal. Give yourself the grace to accept those
moments when it's difficult to cover everything. Remember, the goal is to
understand the material deeply, not just to rush through it.

One crucial guideline to follow: Do not move on to the next day's material until you
have completed the day you are on. This ensures that you have a strong foundation
before progressing further.

Your journey is unique, and your progress may vary daily. The ultimate goal is to
achieve four "high" or "very high" scores consistently in your readiness
assesments. When you reach this milestone, you'll be ready to tackle the NCLEX
exam with confidence.

Stay motivated, stay focused, and never underestimate the power of persistence.
You've come this far, and you're well on your way to achieving your dream.

Good luck, and remember that your hard work and dedication will pay off. You've
got this!

202
 Archer Review

6-Week Study Plan

Sunday Monday Tuesday Wednesday Thursday Friday Saturday
Video: Video: Video: Video: Video:
Medical Positioning Dosage
Lab Values Fluids and Calculation &
Terminology &
Week & ABG
Interpretation
Electrolytes
Part I, II, & III
Medication
Administration
& Diets
and Nutrition Pharmacology
Part I
Review Missed
Questions and
Review Notes
55 Qbank 55 Qbank 55 Qbank 55 Qbank 55 Qbank
questions questions questions questions questions

Video: Video: Video: Video: Video:

EKG Interpretation Pharmacology Legal and
Pharmacology
Week Lines, Tubes,
and Drains, &
Assistive Devices
Part II &
All About NGN
& EKG Changes
with Electrolyte
Part III &
Pharmacological
and Parenteral
Ethical Concepts
& Cultural
Considerations
Review Missed
Abnormalities Therapies Questions and
Review Notes
65 Qbank 65 Qbank 65 Qbank 65 Qbank Readiness
questions questions questions questions Assessment

Video: Video: Video: Video: Video:

The Immune
Week The Endocrine
System
The
Cardiovascular
The Respiratory
System & The
System & The
Integumentary
The
Gastrointestinal Review Missed
System Nervous System System System Questions and
Review Notes
Readiness CAT Readiness
75 Qbank Exam 75 Qbank Assessment
Assessment questions questions

Video: Video: Video: Video: Video:

The Renal The Musculoskeletal Pediatrics & Maternity &
Week System & The
Reproductive
System & The
Hematological
Oncology Growth and
Development
Fetal Heart Rate
Monitoring Review Missed
System System Questions and
Review Notes
Readiness 75 Qbank CAT Readiness
Assessment Exam 75 Qbank Assessment
questions questions

Video: Video: Video: Video: Video:

Mental Health,
Critical Care & Prioritization,
Week Labor and
Delivery
Psychosocial
Integrity, &
Therapeutic
Reduction of Risk
Potential
Delegation, &
Testing Strategies
Basic Care
and Comfort Review Missed
Communication Questions and
Review Notes
Readiness 85 Qbank CAT 85 Qbank Readiness
Assessment questions Exam questions Assessment

Video: Video: Video: Video:

Review Missed
Week Management
of Care
Safety and
Infection Control
Health Promotion
and Maintenance
Physiological
Adaptation
Questions and
Review Notes
Pass Your
NCLEX!
Readiness CAT
Assessment 85 Qbank Exam 85 Qbank NO TEST QUESTIONS!
questions questions

All Qbank questions should be done in tutorial mode (all subjects, all lessons)

203
 Archer Review

12-Week Study Plan

Sunday Monday Tuesday Wednesday Thursday Friday Saturday
Video: Video: Video: Video: Video:
Fluids and Fluids and Fluids and Cultural
Week Lab Values Electrolytes
Part I
Electrolytes
Part II
Electrolytes
Part III
Considerations

25 Qbank 25 Qbank 25 Qbank 25 Qbank Review Missed

questions questions questions questions Questions

Video: Video: Video: Video: Video:

Diets and Medical Lines, Tubes, and
Week Nutrition &
Positioning
Terminology
& Medication
Dosage
Calculation
Pharmacology
Part I
Drains & Assistive
Readiness
Devices Review Missed
Administration Assessment Questions

25 Qbank 25 Qbank 25 Qbank 25 Qbank Readiness

questions questions questions questions Assessment

Video: Video: Video: Video: Video:

Week Pharmacology
Part II
EKG
Interpretation
Pharmacology
Part III
ABG Interpretation
& EKG Changes
with Electrolyte
Legal and Ethical
Concepts
Abnormalities

25 Qbank 25 Qbank Readiness 25 Qbank Review Missed

questions questions Assessment questions Questions

Video: Video: Video: Video: Video:

The Cardiac- The Nervous
Week Cardiovascular
System & Electrical
Hemodynamic
Parameters, Shock,
& Blood Flow
The Respiratory
System (1st Half)
The Respiratory
System (2nd Half)
System
(1st Half) Review Missed
Conduction Through The Heart
Questions
Readiness 25 Qbank 25 Qbank Readiness
Assessment 25 Qbank Assessment
questions questions questions

Video: Video: Video: Video: Video:

The Nervous The The
Week System
(2nd Half)
Gastrointestinal
System (1st Half)
Gastrointestinal
System (2nd Half)
The Renal System
(1st Half)
The Renal System
(2nd Half)

35 Qbank Readiness 35 Qbank Review Missed

35 Qbank Assessment
questions questions questions Questions

Video: Video: Video: Video: Video:

Week The Reproductive

System
The Endocrine
System (1st Half)
The Endocrine
System (2nd Half)
The Hematologic
System (1st Half)
The Hematologic
System (2nd Half) Review Missed
Questions
Readiness
45 Qbank Assessment 45 Qbank 45 Qbank 45 Qbank
questions questions questions questions

All Qbank questions should be done in tutorial mode (all subjects, all lessons)

204
 Archer Review

12-Week Study Plan

Sunday Monday Tuesday Wednesday Thursday Friday Saturday
Video: Video: Video: Video: Video:
The The The
Testing
Week The Immune
System
Integumentary
System
Musculoskeletal
System (1st Half)
Musculoskeletal
System (2nd Half) Strategies Review Missed
Questions
Readiness 45 Qbank 45 Qbank 45 Qbank CAT
Assessment questions questions questions Exam

Video: Video: Video: Video: Video:

Labor and Labor and
Week Maternity
(1st Half)
Maternity
(2nd Half)
Delivery
(1st Half)
Delivery
(2nd Half)
Pediatrics
(1st Hour)

Readiness
Assessment 55 Qbank 55 Qbank 55 Qbank Review Missed
questions questions questions Questions

Video: Video: Video: Video: Video:

Week Pediatrics
(2nd Hour)
Pediatrics
(Finish Lecture)
Fetal Heart Rate
Monitoring
& Growth and Mental health Oncology
Development Review Missed
Questions
Readiness Review Readiness CAT
65 Qbank 65 Qbank
questions questions Assessment Assessments Exam
(two lowest areas)

Video: Video: Video: Video: Video:

Week Critical Care Prioritization Delegation

All About the NGN
& Therapeutic
Communication
Physiological
Adaptation

Readiness Readiness Review Missed

Assessment 65 Qbank Assessment 65 Qbank
questions questions Questions

Video: Video: Video: Video: Video:

Week Basic Care and

Comfort
Health Promotion
and Maintenance
Management
of Care
Safety and
Infection Control
Reduction of
Risk Potential Review Missed
CAT Exam Questions
Readiness Review Readiness Readiness Review Readiness CAT
Assessment Assessments Assessment Assessments Exam
(two lowest areas) (two lowest areas)

Video: Video: Video: Video: Video:

Pharmacological Choose 2 Videos Choose 2 Videos
Week and Parenteral
Therapies
Psychosocial
Integrity
Cultural
Considerations to Review a
Second Time
to Review a
Second Time
Pass Your
NCLEX!
Readiness Review Missed Readiness Review Missed
Assessment Questions Assessment NO TEST QUESTIONS!
Questions

All Qbank questions should be done in tutorial mode (all subjects, all lessons)

205
DAILY PLANNER DATE:
S M T W T F S

MOOD: TODAY'S GOALS HIGH OR VERY HIGH

READINESS ASSEMENTS
1 2 3 4 5 6

REMINDER TO:
It isn’t going to be easy,
but it will be worth it.
TODAY'S STUDY
PLAN:
TIME: EVENT:
SELF CARE TOPICS TO REVIEW

TOTAL
MINUTES:

GOAL MET?

WATER INTAKE:

DAILY QUESTIONS NOTES HOW DID YOU FEEL ABOUT

YOUR STUDYING TODAY?

GOAL

COMPLETED

AREAS OF STRENGTH AREAS FOR GROWTH FOR TOMORROW:

Copy so that you can use this several times.

IF YOU CAN

DREAM IT
YOU CAN

DO IT
ArcherReview
INTERACT, LEARN, AND EXCEL!