Running head: NCLEX REVIEW 1

Nclex review with pharmacology focus

Arielle Bass

Jacksonville University

April 20, 2015

NCLEX REVIEW 2

Nclex review with pharmacology focus

 Antihypertensive Medications
o Some affect RAAS
 Low blood pressure/low sodium/high potassium triggers release of renin
 Renin activates angiotensinogen
 Angiotensinogen leads to conversion to angiotensin 1 in the liver
 Angiotensin 1 becomes angiotensin 2 in the lungs
 Angiotensin 2 binds to receptors on adrenal gland to release aldosterone
 Angiotensin 2 also vasoconstricts (increase BP)
 Aldosterone leads to sodium retention and water retention to increase
blood volume and BP
 Medications that affect RAAS
 ACE Inhibitors
o End in “pril”
o Blocks conversion of angiotensin 1 to angiotensin 2 in the
lungs
o Major S/S:
 Facial swelling (angioedema)
 Dry cough (LUNGS)
 Hypotension!
 Hyperkalemia
 Weakness
 Cardiac arrhythmias
 ARB
o End in “sartan”
o Blocks binding of angiotensin 2 to receptors
o Major S/S:
 Angioedema
 Hypotension!
 Hyperkalemia
 Weakness
 Cardiac arrhythmias
o Diuretics (all can cause hypotension!!)
 Loop diuretics (Furosemide a.k.a. Lasix)
 Used for heart failure with pulmonary congestion
o Effective if breathing relieved/oxygenation improved
 Leads to extensive fluid loss
o Monitor for dehydration
o Orthostatic hypotension
 Potassium wasting
o Monitor for hypokalemia!
NCLEX REVIEW 3

 Weakness
 Stomach upset
 Cardiac arrhythmias
 Possible decrease in sodium as well
o Monitor for neurological changes
 Thiazides
 Hydrochlorothiazide
 Usually first line therapy treatment for hypertension
o Less fluid loss than loop diuretics
 Potassium wasting
o Monitor for cardiac arrhythmias, weakness
 Potassium sparing diuretics
 Spironolactone
o Antagonizes aldosterone
 Amiloride and triameterene
 All of these lead to hyperkalemia
o Cardiac arrhythmias (EKG Monitor!)
o Stomach upset
o Weakness
 Also can cause dehydration
o Tented skin
o Poor capillary refill
o Dry mucous membranes
o Altered LOC
o Calcium channel blockers
 All end in “dipine” except for verapamil
 S/S:
 Hypotension* safety
 Cardiac arrhythmias
 Edema
 GI upset
 Headache
o Beta blockers
 All have “lol” in the name
 S/S:
 Reflex tachycardia
 Dizziness
 Shortness of breath
 Depression
 Monitor for possible:
 Heart failure and fluid overload!*
NCLEX REVIEW 4

o Others
 Mannitol
 The number one medication used to decrease elevated ICP or
intraocular pressure
o Effectiveness seen in decreased pressure and symptoms of
ICP elevations (headache, irritability, seizures, etc.)
o Should see increase in renal function!!
 Hydralazine
 Vasodilator
 S/S:
o Tachycardia
o Angina
o Edema
o Dyspnea
o Tremors
o Headache
 HYPOTENSION
 Nitroprusside
 Any medication with “nitro” in the name is a vasodilator
o Causes hypotension
o Hopefully alleviates angina (otherwise MI)
NCLEX REVIEW 5

 Antilipidemia drugs
o The labs
 Triglycerides
 Want less than 149
 Cholesterol
 Dietary intake should be less than 300 mg per day
 Want cholesterol less than 200
 HDLs
 Want greater than 60!
 Good cholesterol
 LDLs
 Want less than 100
o Drugs:
 HMG-CoA reductase inhibitors (a.k.a. the statins!)
 All have “statin” in the name
 S/S:
o Muscle/joint pain
o H/A
o Fatigue
o Myopathy
o Rhabdomyolysis****
 Can cause renal failure
o Liver damage
 Do not give with
o Erythromycin
o Immunosuppressants
o Fibric acid agents
o Grapefruit juice
 Give with:
o Evening meal
 Bile acid sequestrants
 Excretes cholesterol in stool
 Take before meals with fluids*
 S/S:
o GI s/s
o Abdominal pain
o Yellowing of skin/sclera ***
 Drugs:
o Cholestyramine
 Do not take with food!**
 Increased risk for bleeding
NCLEX REVIEW 6

 Increases liver labs

 Impairs nutrient absorption
 Niacin
 Take with cold water to decrease flushing
 S/S:
o Hepatotoxic
o Gout
o Flank/joint/stomach pain (report!)
 Fibric acid agents
 Take with meals!*
 Gemfibrozil
o Gallstone risk
o Liver damage
NCLEX REVIEW 7

 Drugs for angina and MI

 Myocardium (heart muscle)
o Gets blood from right/left coronary arteries (from aortic sinuses)
o CAD
o Leading cause of death in U.S.
o Causes myocardial ischemia
 Narrowing/occlusion of coronary arteries
 No nutrients or oxygen can reach tissues=MI
 Asymptomatic for years
o Commonly caused by:
 Atherosclerosis
o Fatty plaque on walls of arteries
o BV cannot dilate well
 Angina pectoris
o Acute chest pain caused by insufficient oxygenation of tissue
o Constant, intense pain in chest
o “Crushing” or “constricting”
o Radiates
o Left shoulder
o Left arm
o Back
o Jaw
o Midepigastric
o Abdominal
o In women, see atypical S/S:
o Fatigue *
o GI upset
o Nausea
o Heartburn
o Sweating
o Generally, S/S
o Anxiety
o Pallor
o Feeling of impending doom
o Dyspnea
o Cyanosis
NCLEX REVIEW 8

o Excessive sweating
o Tachycardia
o High BP
o Precipitating factors
o Physical exertion
o Emotional excitement (I.E. Stress)
o Pain subsides when these factors are alleviated
 Usually within 5 to 10 minutes
o Types of angina
o Stable
 Predictable frequency, intensity, and duration
 Pain relieved by rest
o Unstable
 More frequent, intense episodes
 Occur even during rest
 Type of acute coronary syndrome
o Vasospastic/Prinzmetal’s
 Caused by spasms of coronary arteries that impair oxygenation
 May or may not be related to atherosclerosis
 Occurs during rest or unpredictably
o Silent
 Absence of chest pain
 Asymptomatic despite occlusion
 Risk for sudden death or MI
o Angina looks like heart attack or other problems
o Not often fatal
o Rule out GI or pulmonary origins
o Nonpharmacological treatment of angina:
o Lifestyle modification:
 Limit alcohol
 Eliminate high saturated fat and cholesterol from diet
 Keep cholesterol and lipid levels in range
 Avoid tobacco
 Monitor BP
 Exercise regularly
 Monitor weight
 Monitor glucose levels
 Limit salt intake
NCLEX REVIEW 9

 Sleep between five to eight hours

o Percutaneous coronary intervention (PCI)
 Used for coronary artery obstruction
 Atherectomy-remove plaque
 Angioplasty-using balloon catheter to compress plaque against
vessel walls
 Stent placement following either procedure to prolong reclusion
(can also use medications)
o Coronary artery bypass graft surgery (CABG)
 For severe cases where PCI ineffective
 Removes leg vein to graft between aorta and coronary artery above
occlusion
o Pharmacological interventions for angina:
o Goal to:
 Reduce frequency/intensity of chest pain
 Improve exercise tolerance and ability to perform ADLs
 Extend patient’s life by preventing HF or MI
o Two categories of drugs (work by reducing myocardial demand for
oxygen):
 1)Stop an occurring angina episode
 2)Decrease frequency of future episodes
 Does so by:
o Slowing heart rate
o Vasodilation (reduces preload)
o Reduced contractility of heart
o Lowering BP (lower resistance in heart=reduces afterload)
 Three classes of drugs and miscellaneous category:
o These drugs can be combined if the angina episodes are
unresolved by one class alone
o Immediately report:
 Excessive hypotension
 Dysrhythmias
 Reflex tachycardia
 Headache that persists for more than 15-20 minutes
with altered LOC
 Decreased urine output
 Seizures
 Chest pain not relieved by three nitroglycerin
tablets
NCLEX REVIEW 10

o Organic nitrates
 Good for terminating an occurring episode of
angina
 Long-acting doses can prevent future episodes
 Dilates veins=reduces blood return to heart
(decreased preload)
 Leads to decreased CO and lower oxygen
demand
 Dilates coronary arteries=increases blood return to
heart muscle
 Beneficial in treating vasospastic angina
episodes
 Mechanism of action
 Forms nitric acid (vasodilator) in vascular
smooth muscle
 Relaxes arterial and venous smooth muscle
o Two types of organic nitrates:
 Long acting
 I.E. Isosorbide dinitrate
o Decreases frequency/intensity of
episodes
 Can also be used for symptoms of HF
 Develop tolerance over time (can rapidly
decrease with withholding of medication)
o I.E. removing transdermal patch for
several hours or not giving night-
time dose of oral drug
o At night, decreased oxygen demands
for heart=fewer angina episodes
 Short acting
 I.E. Nitroglycerin (Prototype)
o Quickly stops occurring episode or
one about to occur
o Can be given:
 Sublingual
 PO-prophylaxis only
 Lingual
 IV-use glass bottle
 Transdermal-prophylaxis
only
NCLEX REVIEW 11

 Topical-use gloves
 Extended release-prophylaxis
only
o If angina not respond to medication
within 10 to 15 minutes, may be MI
o Cover IV fluid to avoid exposure to
light
o Adverse effects:
 Flushing
 Headache (from dilated BV)
 Reflex tachycardia (give beta
blocker)
 Orthostatic hypotension
 Circulatory collapse
 Syncope
o Do not give to patients with:
 Hypotension
 Head trauma
 Pericardial tamponade (fluid
in pericardium)
 Constrictive pericarditis
(Heart cannot raise BP with
vasodilation)
 Glaucoma (not extended
release)
 Dehydration
o Do not give with:
 Viagra, Levitra, Cialis (drops
BP)
 Alcohol (drops BP)
 Antihypertensive drugs
(drops BP)
 Hawthorn (drops BP)
o May increase levels of:
 Urinary catecholamines
o Treat severe hypotension with IV
normal saline
o Beta-adrenergic antagonists (beta blockers)
 Prevent stable angina pain (prophylaxis)
 Decreases HR and contractility=decreases CO
NCLEX REVIEW 12

 Patients do not develop tolerance

 Good for patients with HTN and CAD
 Does not work well with vasospastic angina
 End in “lol”
 Adverse effects:
 Fatigue
 Insomnia
 Decreased libido
 Altered LOC
 Agranulocytosis
 If abruptly stopped:
o Palpitations
o Rebound HTN
o Dysrhythmias
o MI
 Prototype: Atenolol (Tenormin)
 Used for:
o HF
o HTN
o Angina
o MI
 Begin with low doses and titrate up slowly
 Monitor ECG while administering
 Monitor BP and pulses
o Hold if pulse < 60 beats
o Hold if hypotensive
 Adverse effects:
o Fatigue
o Weakness
o Bradycardia
o Hypotension
 BLACK BOX WARNING
o Patients with ischemic heart disease
should not stop taking medication
suddenly
 Gradual over 1-2 weeks
 Restart if angina worsens
 Do not use with patients with:
o Severe bradycardia (give atropine)
NCLEX REVIEW 13

o AV heart block
o Cardiogenic shock
o HF
o Severe hypotension (give atropine)
 Be careful with:
o Use with CCBs (excessive cardiac
suppression)
o Digoxin (AV heart block)
o Antihypertensive medications
(further BP drop)
o Anticholinergics (decreased
absorption in GI tract)
 Increases the following lab values:
o Uric acid (gout)
o Lipids
o K
o Creatinine
o Antinuclear antibody
o Calcium channel blockers (CCB)
 Used for stable angina with patients that do not
tolerate beta blockers
 Can combine this class with others for persistent
angina
 Dilates arterial vessels=decreases BP and CO
 Can decrease HR and dilate coronary arteries
 Can be used for:
 HTN
 Dysrhythmias
 Angina pain
 Vasospastic angina
 Prototype: Diltiazem (Cardizem, Cartia XT, etc.)
 Useful with atrial dysrhythmias and HTN
 Monitor continuously on IV
 Adverse effects:
o Vasodilation
 Headache
 Dizziness
 Edema in ankles/feet
o Abrupt discontinuation
NCLEX REVIEW 14

 Angina episode
 Do not use with patients with:
o AV heart block
o Sick sinus syndrome
o Severe hypotension
o Bleeding aneurysm
o Intracranial surgery
o Renal/liver impairment
 Do not use with:
o Other cardiovascular drugs
 Complete heart block (give
Calcium chloride)
 HF
 Dysrhythmias
 Increases levels of digoxin
 Increased hypotensive effect
o St. John’s wort and ginseng
(decreased use)
o Garlic, hawthorn, goldenseal
(increase hypotensive effect)
 For overdose:
o Atropine
o Vasopressor for hypotension (I.E.
dopamine)
o Ranolazine (Ranexa)
 Prevents future angina episodes (does not stop
current attack)
 Used for chronic angina that cannot be managed by
other classes
 Shifts metabolic function of heart muscle
 Heart uses glucose for energy instead of
fatty acids
 Decreases metabolic rate and oxygen
demand
 Does not affect BP or HR much
 Adverse effects:
 Dizziness
 Nausea
 Constipation
NCLEX REVIEW 15

 Headache
 Prolonged QT interval
 Bradycardia
 Hypotension
 Acute coronary syndrome
o Collection of symptoms resulting from sudden occlusion of coronary artery
o Usually from piece of plaque entering systemic circulation and adherence
of platelets to location where plaque came from
o Two types:
o Unstable angina
 Thrombus not completely occluding coronary artery
 Extreme chest pain
 Goals
o Relieve chest pain
 Nitrates
 Morphine
o Administer antiplatelet drugs to prevent clot enlargement
 Aspirin
 Clopidogrel (See below)
o Myocardial infarction (MI)
 Thrombus completely occluding coronary artery
 Tissue becomes ischemic
 Extreme chest pain
 Patient will die in 20 minutes unless blood supply restored
 Tissue necrosis leads to changes in the following labs
o Creatine kinase (CK):
 Normal Range: men (5-35 mcg/L); women (5-25
mcg/L)
 Initial elevations seen 3-8 hours after MI
 Highest 12-24 hours after MI
o CK-MB:
 Normal Range: greater than 3-5 % total CK
 Initial elevations seen 4 to 6 hours after MI
 Highest 10-24 hours after MI
o Erythrocyte sedimentation rate-Takes longer for lab values
to alter; lasts longest
 Normal Range: men (15-20 mm/hr); women (20-30
mm/hr)
 Initial elevations seen 2-3 days after MI
NCLEX REVIEW 16

 Highest 4-5 days after MI

o Total lactate dehydrogenase (LDH)-Takes longer for lab
values to alter
 Normal Range: 70-250 units/L
 Initial elevations seen 12-42 hours after MI
 Highest 2-5 days after MI
o Myoglobin-not specific to cardiac tissue
 Normal Range: 12-90 ng/mL
 Initial elevations seen 2-6 hours after MI
 Highest 8-12 hours after MI
o Troponin I-fastest indicator
 Normal Range: 12-90 mcg/L
 Initial elevations seen 1-3 hours after MI
 Highest 24-36 hours after MI
o Troponin T-fastest indicator
 Normal range : Less than 0.2 mcg/L
 Initial elevations seen 1-3 hours after MI
 Highest 24-36 hours after MI
 Early intervention increases survival probability
o Restoring blood supply to damaged tissue before necrosis
occurs
 Methods:
 Thrombolytics (See below)
 PCI (See above)
o Reduce myocardial oxygen demand to prevent infarction
 Methods:
 Organic nitrates (See above)
 Beta blockers (See above)
 CCBs (See above)
o Control/Prevent MI-associated dysrhythmias
 Methods:
 Beta blockers and similar drugs (See above)
o Reduce post- MI mortality
 Methods:
 Aspirin
o NSAID
o Irreversible platelet aggregation
inhibition
o Take with milk!
NCLEX REVIEW 17

o Monitor glucose values

 Hypoglycemia
o Adverse effects:
 GI discomfort
 Bleeding
o Do not give to patients with:
 Anticoagulant therapy
o Do not give with:
 Phenobarbital (decrease
aspirin’s effect)
 Antacids (decrease aspirin’s
effect)
 Glucocorticoids (decrease
aspirin’s effect)
 Other NSAIDs (decreases
effect)
 Beta blockers (decreases
effect)
 Potassium sparing diuretics
(decreases effect)
 Sulfa drugs (decreases effect)
 Penicillin (increase aspirin’s
effects)
 Sulfonamides (increase
aspirin’s effects)
 Alcohol (increased gastric
ulcer risk)
 Steroids (increased gastric
ulcer risk)
 Other NSAIDS (increased
gastric ulcer risk)
o May increase the following lab
values:
 PT
o May decrease the following lab
values:
 Cholesterol
 K
 Abnormal liver panel
 Beta blockers
NCLEX REVIEW 18

 Angiotensin-converting enzyme (ACE)

inhibitors
o End in “pril”
o Manage severe MI pain and anxiety
 Methods:
 Narcotic analgesics
o Morphine sulfate
o Fentanyl
o Prevent enlargement of thrombus
 Methods:
 Anticoagulants
 Antiplatelet drugs
o Thrombolytics
o Dissolve clots blocking coronary arteries
 Restores blood circulation
o Associated with reperfusion of heart following MI
o Anticoagulant therapy used following thrombolytic application
 Prevents future clots
o Most effective 20 minutes to 12 hours after MI symptoms start
 After 24 hours, not effective
o Rapidly destroyed by body
o Narrow safety margin
 Risk for:
o Excessive bleeding
o Impaired clotting
o Prototype: Reteplase (Retavase)
 Cleaves plasminogen to form plasmin
 Plasmin degrades fibers of thrombi (clots)
 Given as early as possible following onset of MI S/S
 Acts within 20 minutes
 Can give a second bolus 30 minutes later
 Following clot removal, patient put on heparin
 Off label use for DVT and occluded catheters
 Do not shake mixture
 Do not mix this drug in IV with other drugs
 Never give this drug and heparin together
 Adverse effects:
NCLEX REVIEW 19

o Abnormal bleeding at injection or catheter sites (do not

give with other blood thinning drugs or ginkgo)
o Dysrhythmias
 Do not use with patients with:
o Active bleeding
o History of CVA
o Recent surgery
 Decreases the following labs:
o Plasminogen
o Fibrinogen
o Antiplatelet and Anticoagulants
o 160-325 mg aspirin given with beginning symptoms of MI
 Concurrent use in days following MI decreases mortality
o 75-150 mg/day
o Low risk for GI bleeding
o Clopidogrel (Plavix)
 Adenosine diphosphate receptor blocker
 Antiplatelet medication
 Prophylaxis against:
o Thrombotic stroke
o MI
 For high risk patients
o Loading dose (larger than normal) given prior to PCI
o Glycoprotein IIb/IIIa: abciximab (ReoPro)
 Antiplatelet drug
 Used for:
o Unstable angina
o MI
o Patients undergoing PCI and 12 hours after
o Heparin
 Anticoagulant
 Given following diagnosis of MI
 Prevents further clot development
 Continued 48 hours or until after PCI
o Warfarin (Coumadin)
 Anticoagulant
 Patient put on following PCI procedure
o Ginseng
NCLEX REVIEW 20

 Possible cardiac benefits (similar to CCBs)

 Anticoagulants, antiplatelets
 Hemostasis
o Stopping of blood flow
 Occurs once clot is formed and no risk for hemorrhage
o Protects body from external/internal injury
o Balance between blood fluidity and coagulation
o Involves use of clotting factors
o Lab values associated with coagulation disorders: (normal values depend on
individual patient)
 Activated clotting time
 Used to monitor high-dose heparin therapy and for surgical
procedures
 Normal values: 70-180 seconds; 400-500 seconds for coronary
bypass surgery
 High values=increased bleeding risk (reduce heparin)
 Activated partial thromboplastin (aPTT) *
 Used to monitor heparin therapy
 Normal values: 25-35 seconds
 High values=Increased bleeding risk (reduce heparin)
 Bleeding time *
 For general diagnosis of coagulation disorders
 Normal values: 2-9 minutes in forearm
 Prolonged bleeding time related to low platelet count or
anticoagulant therapy
 Heparin anti-Xa
 Heparin therapy monitoring
 Normal values: 0.3-0.7 IU/mL
NCLEX REVIEW 21

 High values=increased bleeding risk (reduce heparin)

 Platelet count *
 Part of CBC
 Normal values: 150,000-350,000
 <20,000 = thrombocytopenia
 Prothrombin time (PT) *
 Warfarin therapy monitoring
 Normal values: 10-14 seconds
 Normal values: INR: 0.9-1.1
INR 2-3 on Coumadin (higher=DVT); 2.5-3.5 (prevent arterial
thrombi)
 High values=risk for bleeding (reduce dose of anticoagulant)
 Thrombin time
 Used to assess for fibrinogen deficiency and heparin therapy
monitoring
 Normal values: 13-15 seconds
 Higher values with heparin therapy
 Potassium:
 Normal values: 3.5-5
 Blood vessel injury process:
o Vessel injured
o Vessel spasm and constriction
 Limits blood flow
o Platelets become sticky
 Adhere to each other and to damaged area to “plug” area
 Related to adenosine diphosphate, thrombin, thromboxane A2 (enzymes)
 Adhesion related to glycoprotein IIb/IIIa receptors
o Breakdown of bound platelets
 Attracts more platelets to area
o Coagulation
 Formation of insoluble clot (fibrin)
o Collagen triggers coagulation cascade
 Fibrin threads connect and trap blood particles
 Plasma proteins converted to active forms
o Two pathways triggered
 Intrinsic pathway-related to injury
 Extrinsic pathway- related to blood leaking into tissue space
 Both lead to formation of clot
o Prothrombin activator/prothrombinase formed following injury
NCLEX REVIEW 22

 Converts prothrombin to thrombin (enzyme)

 Thrombin converts fibrinogen to fibrin (protein)
o Blood clotting takes about 6 minutes normally
 Several clotting factors (I.E. fibrinogen) made by liver
o Inactive until injury occurs
o Vitamin K needed for creation of these clotting factors
o Problems with coagulation associated with liver impairment in patients
 Fibrinolysis
o Process of clot removal
o Occurs 24-48 hours after clot formation until clot is gone
o Process:
 Once clot formed, BV cells secrete tissue plasminogen activator (TPA)
 TPA converts plasminogen (inactive) to plasmin (enzyme)
 Plasmin breaks down fibrin surrounding clot
 Regulated to remove only clots that are not necessary to protect
homeostasis in body
 Common clotting disorders
o Von Willebrand’s disease (vWD)
 Hereditary bleeding disorder
 Most common inherited coagulation disorder
 Deficiency of von Willebrand factor (protein)
 Needed for platelet aggregation
 Treated with:
 Factor VIII
 Desmopressin
o Releases stored vWF
o Hemophilia A (classic hemophilia)
 Herditary
 Lack of clotting factor VIII
 Majority of cases
 Therapy includes:
 Administration of frozen plasma with clotting factor
o Hemophilia B (Christmas disease)
 Hereditary
 Lack of clotting factor IX
 Therapy includes:
 Administration of frozen plasma with clotting factor
o Thrombocytopenia
 Most common coagulation disorder
NCLEX REVIEW 23

 Deficiency of platelets (below 150,000 m3)

 Due to decreased platelet production/increased destruction
 Bone marrow suppression
o Chemotherapy administration
o Immunosuppressant therapy
 Thromboembolic disorders
o Conditions in which the body forms undesirable clots
o In arteries or veins
 Arterial- cut off blood flow
 Can lead to ischemia of tissue, infarction, death
 Related to MI and stroke
 Veins-settle in legs mostly
 Sluggish blood flow
 Leads to deep vein thrombosis (DVT)
o Once thrombus (stationary clot) formed, fibrin can add on to make it larger
 Can form in atria with atrial fibrillation (when blood is pooling from lack
of contraction)
o Embolus
 Traveling clot
 Embolus in right atrium can cause pulmonary emboli (to lungs)
 Embolus in left atrium can cause stroke/arterial infarction (to body)
 These can occur as a result of:
 Surgical procedures
 Angiography
 Indwelling catheters
 Mechanical heart valves
 Three types of coagulation modifiers:
o Prevention of clot formation
 Anticoagulants
 Inhibition of specific clotting factors
 Diminishes clotting action of platelets by creating negative charge
 Increases normal clotting time
 “Blood thinners”
 Primarily for prevention of thrombi in veins
 Medications often started IV or SQ for immediate response against
thromboembolic disorders
 Adverse effects:
o Nausea
o Vomiting
NCLEX REVIEW 24

o Thrombocytopenia
o Anemia
o Hemorrhage
 Prototype: Heparin (unfractionated)
o Amplifies Antithrombin III (protein)
 Inactivates thrombin and other enzymes to inhibit
coagulation
o IV administration-immediate
o SQ administration-1 hour onset; never massage site; don’t
draw back syringe
o Indirect thrombin inhibitor
o Naturally found in liver and lining of BV
o Does not dissolve existing clots
o Used for:
 DVT
 Pulmonary embolism
 Unstable angina
 Evolving MI
 Prevention of thrombosis
o Poorly absorbed in GI tract
o Never use IM route
o Dose calculated by weight, aPTT value, and condition
being used for
o Adverse effects:
 Abnormal bleeding
 Prolonged aPTT (stop the infusion)
 Thrombocytopenia (severity increases 5-10 days
after start of therapy)
 Thrombosis
o BLACK BOX WARNING
 Epidural or spinal hematomas can form while on
heparin therapy
 This can lead to paralysis
 Monitor neurological function!!
o Do not use with patients with:
 Active internal bleeding
 Bleeding disorders
 Severe HTN
 Recent trauma
NCLEX REVIEW 25

 Intracranial hemorrhage
 Bacterial endocarditis
o Do not use with:
 Other oral anticoagulants (increases bleeding effect)
 Drugs that inhibit platelet aggregation
 Aspirin and NSAIDs (increases bleeding
effect)
 Nicotine-inhibit anticoagulation
 Digoxin-inhibit anticoagulation
 Tetracyclines-inhibit anticoagulation
 Antihistamines -inhibit anticoagulation
 Ginger, garlic, green tea, feverfew, ginkgo
(increases bleeding effect)
o Increases the following lab values:
 Free fatty acids
 AST
 ALT
o Decreases the following lab values:
 Cholesterol
 Triglycerides
o If overdose:
 Protamine sulfate IV
 Prototype: Warfarin (Coumadin)
o Vitamin K antagonist
o Used for prevention of the following in patients having
hip/knee surgery or with indwelling PICC lines or
prosthetic heart valves:
 Stroke
 MI
 DVT
 PE
o Also used as prophylaxis to prevent clots in patients after
MI and A fib
o Takes several days to reach therapeutic effect (oral
administration)
 Bound to plasma proteins
o If abnormal bleeding occurs:
 Administer IM or SQ Vitamin K
o BLACK BOX WARNING
 Can cause fatal bleeding
NCLEX REVIEW 26

 Monitor INR lab values

 Teach patients S/S to report
o Do not use with patients with:
 Recent trauma
 Active internal bleeding
 Bleeding disorders
 Intracranial hemorrhage
 Severe hypertension
 Bacterial endocarditis
 Severe renal/liver impairment
o Do not use with:
 Alcohol (over two drinks/day men; over one
drink/day women)-increases effects of warfarin
 NSAIDs-increases effects of warfarin
 Diuretics-increases effects of warfarin
 SSRIs-increases effects of warfarin
 Steroids-increases effects of warfarin
 Antibiotics/vaccines-increases effects of warfarin
 Vitamin K-decreases effects of warfarin
 OTC drugs not approved by doctor-increases effects
of warfarin
 Ginkgo, green tea, feverfew, garlic, cranberry,
chamomile, ginger- -increases effects of warfarin
o Dietary considerations:
 Avoid foods high in Vitamin K
 Asparagus
 Broccoli
 Cabbage
 Cauliflower
 Kale
 Low-molecular-weight heparins (LMWHs)
o End in “parin”
o Specific inhibition of Factor X
o Longer duration of action
o IV administration
o More stable response than heparin
 Fewer lab follow-up appointments
o Less likely to cause thrombocytopenia
o Family can administer SQ injections
NCLEX REVIEW 27

 Ensure that injected in fatty layers of abdomen or

above iliac crest
 Avoid periumbilical area by 2 inches
o Preferred drug for DVT prophylaxis
o Adverse effects:
 Bleeding
 Nausea
 Vomiting
 Hematoma
 Local pain
 Pancytopenia
 Hemorrhage
 Direct thrombin inhibitors
o Lepirudin (Refludan)
o Three end in “rudin”
o Bind to thrombin’s active site
 Prevents formation of fibrin clots
 Works on both circulating thrombin and already
formed clots
o Limited therapeutic use alone
 Used with aspirin as prophylaxis
o Adverse effects:
 Fever
 Nausea
 Allergic skin reactions
 Liver impairment
 Bleeding
 Back pain
 Internal hemorrhaging
 Sepsis
 Hemoptysis
 HF
 For anticoagulant therapy, teach the following points:
o Switch to soft toothbrush
o Use electric razor
o Keep pressure on any cuts for a prolonged period of time
o Avoid contact sports, theme parks, physical activities of
that sort
o Assess skin frequently, especially in elderly
 Antiplatelet drugs
NCLEX REVIEW 28

 Inhibition of platelet actions

 Prevention of clots in arteries
 Related to hemostasis
o Too few platelets/diminished function increases bleeding
risk greatly
 Medications:
o Aspirin
 OTC drug
 Binds irreversibly to cyclooxygenase in platelets
 Inhibits formation of thromboxane A2
 Prevents platelet aggregation
 Can last up to a week
 Look at prototype in chapter 27
o ADP receptor blockers
 Irreversibly alters plasma membrane of platelets
 Platelets cannot receive chemical signals to
aggregate
 Prophylaxis to prevent thrombi formation in
patients that just had thromboembolic event
 Medications:
 Prototype: Clopidogrel (Plavix)
o Used for patients who recently had:
 MI
 Stroke
 PAD
o Prophylaxis for unstable angina and
prevention of thrombi in CA stents
and DVT
o Discontinue drug 5 days before
surgery
o Adverse effects:
 Flulike symptoms
 Headache
 Dizziness
 Bruising
 Rash
 Pruritus
 Bleeding
o BLACK BOX WARNING
NCLEX REVIEW 29

 Effectiveness of drug
dependent on metabolic
activation by CYP 450
enyzmes
 Poor metabolizers=less
therapeutic effect
 Increased cardiovascular
effects
o Do not use with patients with:
 Active bleeding
o Do not use with:
 Anticoagulants-increases
bleeding risk
 Other antiplatelet drugs-
increases bleeding risk
 Thrombolytic drugs-increases
bleeding risk
 NSAIDs-increases bleeding
risk
 Aspirin -increases bleeding
risk
 Barbiturates-increased
anticoagulant properties
 Rifampin-increased
anticoagulant properties
 Carbamazepine-increased
anticoagulant properties
 Azole antifungals-decrease
antiplatelet function
 Protease inhibitors-decrease
antiplatelet function
 Erythromycin-decrease
antiplatelet function
 Verapamil-decrease
antiplatelet function
 Feverfew, green tea, ginkgo,
fish oil, ginger, garlic-
increases bleeding risk
 Prasugrel
 Ticagrelor
NCLEX REVIEW 30

 Ticlopidine
 Adverse effects:
 Bleeding
 Abdominal pain
 Dizziness
 Headache
 Increased clotting time
 GI bleeding
 Angina
 Blood dyscrasias
o Glycoprotein IIb/IIIa receptor antagonists
 Glycoprotein IIb/IIIa receptors on surface of
platelets
 Prevent thrombi in patients with:
 Recent MI
 Stroke
 PCI
 IV administration only
 Medications:
 Abciximab (ReoPro)
 Eptifibatide (Integrilin)
 Tirofiban (Aggrastat)
 Adverse effects:
 Dyspepsia
 Dizziness
 Pain at injection site
 Hypotension
 Bradycardia
 Bleeding
 Hemorrhage
 Thrombocytopenia
o Drugs for intermittent claudication
 Intermittent claudication
 Pain/cramping in lower legs
 Increased with exercise
 Symptom of PVD
 Work by increasing flexibility and decreasing
viscosity of RBCs
NCLEX REVIEW 31

 Allows RBCs to enter partially occluded

vessels
 Medications: (oral)
 Cilostazol (Pletal)
o Promotes vasodilation
o Inhibits platelet aggregation
 Pentoxifylline (Trental)
o Antiplatelet function
 Adverse effects:
 Dyspepsia
 Nausea
 Vomiting
 Dizziness
 Myalgia
 Headache
 Tachycardia
 Palpitations
 CNS effects
 HF
 MI
o Removal of existing clot
 Thrombolytic drugs
 Clot dissolved by drug
 Important for removing clots that could impair organ blood flow
o I.E. heart, lungs, brain
 Promote process of fibrinolysis to restore blood flow
 Used for:
o Acute MI
o PE
o Acute ischemic stroke
o DVT
 Therapeutic effect if given within four hours after clot formation
 Monitor vital signs continuously (every 15 minutes first hour,
every 30 minutes rest of infusion, and first 8 hours)
o Monitor lab values
 Hgb
 Hct
 Platelets
NCLEX REVIEW 32

 RBC
 Urinalysis
 ABGs
 aPTT
 aPT
 INR
 Bleeding time
o Teach patient S/S of bleeding
 Increased risk up to 2-4 days post-therapy
 Avoid invasive procedures during therapy and 8
hours after
 Ends in “lase” with the exception of streptokinase
 Adverse effects:
o Superficial bleeding at injection sites
o Allergic reactions
o Internal bleeding
o Intracranial hemorrhage
o HTN
 Prototype: Alteplase (Activase)
o Identical to human tPA
o Converts plasminogen to plasmin to dissolve clots
o Restores patency in IV lines
o Must be given within 12 hours of MI onset and within 3
hours of thrombotic stroke to be effective
o Adverse effects:
 Bleeding
 Spontaneous ecchymoses
 Hematomas
 Epistaxis
 Intracranial bleeding
o Do not use with patients with:
 Active internal bleeding
 Hx of stroke within three months
 Hx of head injury within three months
 Recent trauma or surgery
 Uncontrolled HTN
 Intracranial neoplasm
 Arteriovenous malformation
o Do not use with:
NCLEX REVIEW 33

Anticoagulants-increases bleeding risk

Antiplatelet drugs-increases bleeding risk
NSAIDs-increases bleeding risk
Feverfew, green tea, ginkgo, fish oil, ginger, garlic
-increases bleeding risk
o Increases the following lab values:
 PT
 aPTT
o Promotion of clot formation
 Hemostatics
 Inhibition of fibrin destruction
 Limits bleeding at surgical sites
 “Antifibrinolytics”
 Specific use depending on the drug
 Medications:
o Prototype: Aminocaproic acid (Amicar)
 IV administration
 Prevent bleeding in patients with systemic clotting
disorders
 Inactivates plasminogen to prevent dissolving of
clots
 Can reduce bleeding in 1-2 hours
 Therapeutic serum level: 100-400 mcg/mL
 Assess vital signs frequently
 Can cause hypotension and bradycardia
 Assess for dysrhythmias
 Adverse effects:
 Thromboembolic problems
 Do not use with patients with:
 Disseminated intravascular clotting
 Renal impairment
 Do not use with:
 Oral birth control
o Hypercoagulation
o Thrombin
o Tranexamic acid
 Prevent oozing and bleeding at surgical sites
 Topical
 Adverse effects:
NCLEX REVIEW 34

o Allergic skin reactions

o Headache
o Anaphylaxis
o Thrombosis
o Bronchospasm
o Nephrotoxicity
 Clotting factor concentrates
 Administration of missing clotting factors
o Drug toxicity increased in people with renal/hepatic impairment

 Antipsychotics
o Classic/Typical
 Known for EPS and anticholinergic side effects
 EPS
o Dystonia
o Tremors
o Like Parkinson’s
 Anticholinergic (Monitor for anticholinergic crisis in patient!
o Can’t see
o Can’t pee
o Can’t spit
o Can’t poop
 *Antidote for anticholinergic crisis is physostigmine*
o Stop medication causing reaction
 Haloperidol
 EPS signs and symptoms
NCLEX REVIEW 35

Chlorpromazine
 Anticholinergic signs and symptoms (like antihistamines)
 Fluphenazine (Prolixin)
 This medication and Haloperidol can be given via IM injection for
long term compliance
o Use Z track method in gluteal muscle
o Do not massage site
o Rotate sites
 They decrease positive signs of psychosis
 Hallucinations
 Aggression
 Both can cause excessive lethargy and sexual side effects
 Impact dopamine levels
 Weight gain sometimes common
 Photosensitivity
o Atypical antipsychotics
 Half of them end in “apine”
 Clozapine (Clozaril)
 Agranulocytosis (Monitor for infection)
 Lots of weight gain
 Risperidone (Risperdal)
 Long term compliance IM injection
 Upper outer quadrant of gluteus maximus
 DO NOT Z TRACK
 This class does not cause as much sexual dysfunction or negative
symptoms (blunted affect, etc.)
 Biggest side effects:
o Excessive weight gain
o Diabetes
o Cardiac arrhythmias
o METABOLIC SYNDROME
o Neuroleptic Malignant Syndrome
 From antipsychotics
 Common S/S:
 Muscle rigidity ***
 Fever
 Elevated CPK
 Rhabdomyolysis
 Dysthymias
 Respiratory or cardiac arrest
 Stop medication causing it and never take again.
NCLEX REVIEW 36

 Supportive treatment
 Administer dantrolene *** ANTIDOTE
o Metabolic Syndrome
 Diabetes plus CVD
 BMI >25
 Triglycerides >150
 HDL <40 (this is the good cholesterol)
 Elevated BP
o No medications interact well with alcohol!***

 Anxiolytics and Sedative Hypnotics

o Barbiturates
 Anti-anxiety medication class
 Potentiates GABA
 End in “barbital”
 High risk for respiratory depression**
 Addictive
 Do not stop suddenly**
o Benzodiazepines
 Anti-anxiety medication class
 Potentiates GABA
 Ends in “zepam”
 Do not stop abruptly!***
 Seizures
NCLEX REVIEW 37

 Delirium tremens
 HTN
 Risk for respiratory depression when mixed with alcohol, barbiturates
 Paradoxical reaction to benzos can occur:
 Agitation
 Emotional lability
 Safety risk:
 Drowsiness
 Increased irritability
 Feelings of isolation, depression
 Benzos are used for the following reasons:
 Anxiety reduction
 Promoting sleep
o Temazepam used for elderly
 Shorter half life
 Muscle relaxation
 Prevent seizures
o Diazepam and lorazepam used for status epilepticus
 Produce amnesia
o When stop medications, rebound insomnia
o Midazolam (Versed)
 Used for surgery!
 Antidote for overdose is flumazenil ***
o Other alternative anxiolytic medications
 Clonidine
 Alpha-2 agonist
 Hydroxine (Vistaril)
 OTC
 Buspirone
o Sedative-hypnotics
 Often cause rebound REM
 Cause:
 Drowsiness
 Dependency
 CNS depression
 Benzos and barbiturates can be used
 Other medications that can be used:
 Chloral hydrate
 Zolpidem (Ambien)
 Diphenhydramine (Benadryl)
 Melatonin
NCLEX REVIEW 38

 Trazedone
o Antidepressant
o Priapism**
 Quetiapine
o Antipsychotic

 Stimulants (amphetamines)
o S/S:
 Tremors
 Irritability
 Nervousness
 Tachycardia
 HTN
o Given for:
 ADHD
 Methylphenidate, amphetamine
o Give 30 minutes before meals and early in the day
o Monitor for:
 Paradoxical hyperactivity
 Like hyped up on caffeine
NCLEX REVIEW 39

 Narcolepsy
 Falling asleep at odd times
 Medications:
o Modafinil
o Methylphenidate
 Obesity
 Give anorexiants
o Dextroamphetamine
o Dexatrim
 Reversal of respiratory distress
 Caffeine
 Theophylline

 Anesthesia
o Local vs. General
 Local
 Do not lose consciousness
 Creams, nerve blocks, epidural, spinals
o With spinal anesthesia
 Have them lay flat for at least 2 hours
 Drink fluids
 If headache, may need blood patch!
 Benzocaine and lidocaine!!
 Use with epinephrine
 General
 Lose consciousness
NCLEX REVIEW 40

 Balanced anesthesia
o Decreases amount of one medication given
o Versed often given with this
 Monitor for respiratory depression
o Potential for hyperactivity and delirium
o May use inhaled agents and barbiturates
o May also given neuromuscular blockers

 Antidepressants
o Tricyclics
 End in “ptyline” or “pramine” most of the time
 Examples:
 Amitryptyline
 Imipramine
 Doxepin
o Used for elderly
 ANTICHOLINERGIC
 Sedation properties
 Possible psychosis and increased risk for suicide
o MAOI
NCLEX REVIEW 41

 Examples:
 Phenelzine
 Selegiline hydrochloride
 Need a two week clearance time between this and other antidepressants
 Low tyramine diet to avoid hypertensive crisis
 Avoid:
o Aged cheeses
o Wines
o Smoked meats or sausages
o Caffeine
 Do not take with:
 Meperidine (Demerol)
o Hyperpyrexia-high fever
 Antihypertensives
o Extreme hypotension
o SSRI
 Examples:
 Fluoxetine (Prozac)
 Sertraline (Zoloft)
 S/S:
 Sexual dysfunction
 Weight gain
 Nervousness/insomnia
 SUICIDE!
 Monitor for S/S of serotonin syndrome (stop medication if happens!)
 Altered LOC
 Myoclonus
 Hyperreflexia**
 Sweating
 Withdrawal S/S: (taper drug down to avoid)
 Nausea
 H/A
 Dizziness
 Dysphoria
 Tremor
o Other antidepressants
 Bupropion
 Used also for smoking cessation
 Do not give to seizure patients
 Increases BP
 Trazodone
NCLEX REVIEW 42

 Priapism

 Mood Stabilizers
o Lithium
 Adverse effects:
 N/V
 Polyuria
 Tremor***
o As increased toxicity, worst tremor
 Hypothyroidism
 Altered LOC with increased toxicity
o Seizures
NCLEX REVIEW 43

 Monitor:
 Thyroid function
 EKG
o Carbamazepine
 Do not give with valproic acid!
 S/S:
 N/V
 Agranulocytosis
 Sedation
 Anorexia
 Monitor:
 EKG
 Thyroid
o Valproic Acid
 Monitor liver function
 S/S:
 Thrombocytopenia
o Bleeding risk
 Tremors
o Lamotrigine
 Can stop suddenly but must titrate up slowly to prevent Stevens Johnson
Syndrome (bad rash)
o Gabapentin

 Epileptic drugs
o Work by one of four mechanisms:
 Stimulate GABA
 Examples:
o Barbiturates
 “Barbital”
 Can cause agranulocytosis
 Watch for bleeding
 Monitor liver and kidney function
NCLEX REVIEW 44

o Benzodiazepines
 End in “apam”
 For overdose-Flumazenil!!**
o Others:
 Gabapentin
 Mood stabilizer
 CNS Depression!
 Antagonizing glutamate
 Delaying sodium influx
 Phenytoin
o CNS depression
o Gingival hyperplasia
o Cardiac dysrhythmias
o Hypotension
o Monitor:
 Liver and renal function
 Bleeding disorders
 Delaying calcium influx (Succinimides)
 Ethosuximide
o Lupups
o Leukopenia
 Monitor for infection
o Lethargy
o Suicidal thoughts

 Neuromuscular disorders
o Centrally acting muscle relaxants
 Cyclobenzprine (Flexeril)
 Works on calming muscle excitability
 CNS depression!
 Liver toxicity
o Monitor liver function
 Anticholinergic
NCLEX REVIEW 45

o Direct-acting antispasmodics
 Dantrolene
 Used as antidote for malignant hyperthermia
 Prevents release of calcium ions
 Liver toxicity*
 Muscle weakness
 Drowsiness
o Nondepolarizing blockers
 Tubocuraine
 Blocks acetylcholine to relax muscles during surgery
o Depolarizing blockers
 Succinylcholine
 Blocks acetylcholine
 Can cause:
o Persistent paralysis
o Malignant hyperthermia

 Parkinson’s Disease
o Low dopamine, high acetylcholine
 Causes tremors, dystonia, dementia, etc.
o Drug classes:
 Dopaminergics
 Levodopa-carbidopa (Sinemet)
o Give with meals (N/V risk)
NCLEX REVIEW 46

o Avoid high protein meals****

 Competes with drug binding
o Avoid pyridoxine***
 Bananas, green veggies, liver
o S/S:
 Darkened sweat/urine
 Dyskinesias
 Orthostatic hypotension* (safety!)
 Dysrhythmias*
 Psychosis
 From too much dopamine
 Infection
o Do not give to patients with:
 Potential malignant skin lesions
 Narrow-angle glaucoma
o Do not:
 Stop suddenly:
 Can cause:
o Parkinsonism crisis
o Neuroleptic malignant syndrome
o Monitor:
 Renal and liver function
 Dopamine agonists
 Amantadine (HIV anti-viral drug)
 Bromocriptine
 Pramipexole
 MAO-B inhibitor
 Selegiline hydrochloride (Eldepryl!)*
 Things to note about MAO-Is:
o Avoid foods high in tyramine (hypertensive crisis)
 Aged cheese
 Fermented or dried meat
 Red wine
 Soy sauce
o Need a big wash out period (being off drug) for several
weeks between this and SSRIs or tricyclic antidepressants
o This drug class never plays well with other drugs
 COMT inhibitors
 Think COMT as like cartoon
o Biggest drug is Tolcapone (Tasmar)
 A.K.A. Tasmanian devil
 LIVER FUNCTION!
NCLEX REVIEW 47

o Comtan
 Can use decreased dose of other PD drugs
 Anticholinergics
 Atropine!
o Atropine is the antidote for a cholinergic crisis (see
Alzheimer’s section)
 Benztropine (Cogentin)
 This class reduces tremors and rigidity
 Do not give with:
o Urinary or GI obstruction
o Dysthymias
o Narrow angle glaucoma**
 Elderly can become delirious from anticholinergics*
 Anticholinergic Crisis S/S: (Treat with physostigmine)
o Confusion/hallucinations
o Dilated pupils
o Blurred vision
o Fever
o Tachycardia
o Decreased bowel sounds and urinary retention
o Seizures
o Death
 Nursing interventions for anticholinergics:
o Sugarless hard candy/drinks for dry mouth
o Take with food
o Avoid alcohol (always…)
o Photosensitivity
o Never stop suddenly

 Alzheimer’s Disease
o Low Ach
o Progressive memory loss
o Medications do not cure but slow down symptoms
o Cholinesterase inhibitors (raise Ach levels)
NCLEX REVIEW 48

 Donpezil (Aricept)
 Rivastigmine
o S/S to monitor for:
 Hypotension (safety!)
 LOC change
o Tips:
 Take with food or milk
 Monitor for signs of cholinergic crisis (give atropine!)***
 S-salivation
 L-lacrimation (excessive tearing of eyes)
 U-urination
 D-diarrhea
 G-gastric upset
 E-emesis (vomiting)
 Will also see BRADYCARDIA and increased muscle weakness with
cholinergic crisis
o Memantine
 NMDA receptor antagonist (blocks glutamate)

 Multiple sclerosis
o Degeneration of neurons
o Medications for this condition ALWAYS have the potential adverse effect of
infection******
NCLEX REVIEW 49

o Give:
 Immunomodulators
 Interferon beta
 Glatiramer acetate
 Immunosuppressants
 Mitoxantrone
o Chemo drug
 So think hair loss, GI upset, blue-green urine, etc.
NCLEX REVIEW 50

 Substance abuse
o Opioids
 Examples
 Heroin
 Morphine
 Codeine
 Causes CNS depression**
 Pain relievers**
 Overdose S/S: (Give Naloxone (Narcan))
 Pinpoint pupils**
 Coma
 Respiratory depression
 Withdrawal S/S:
 Sweating
 Runny nose/eyes
 Dilated pupils
 Tachycardia
 HTN
 Fluids coming out of everywhere and nervous…
o Psychostimulants
 Cocaine (CNS stimulation then depression)
 S/S:
o Euphoria
o Psychosis
o Tachycardia
o HTN
o Dilated pupils
o Sleep disturbances/anxiety
o Seizures
o Death
 Withdrawal
o Sleep disturbances (rebound REM)
o Decreased sex drive
o Depression/suicide
 Methamphetamine
 S/S:
o Euphoria
o Massive vasoconstriction
o Psychosis
o HTN
o Stroke
NCLEX REVIEW 51

o Tachycardia
o Sweating
 Withdrawal:
o Dysphoria
o Cravings
o Sleep deprivation
o Excessive eating
o Depressants
 Barbiturates
 Benzodiazepines
 Alcohol
 Withdrawal symptoms
o HTN
o Tachycardia
o Sweating
o Anxiety
o Tremors
o LOC change
o Delirium tremens***
 Seizures progressing to death
 Give Diazepam or Librium to prevent
 Can also give baclofen (decreases spasticity)
 Must supplement thiamine with alcohol addiction
o Wernicke and Korsakoff
 Medications for alcohol rehab
o Disulfram (Antabuse)
 DO NOT DRINK OR SEVERE REACTION
o Naltrexone (ReVia)
 Reduces cravings
 Monitor liver function
o Acamprosate (Campral)
 Increases GABA
o Psychedelics
 LSD

o Anabolic Steroids
 Testosterone
o Others
 Marijuana
 S/S:
o Apathy
NCLEX REVIEW 52

o Dull
o Hypotension
o Bronchitis
o Lung cancer
o Decreased sexual hormones
o In utero effects
 Withdrawal:
o Irritability
o Nervousness
o Reduced appetite
o Weight loss
o Hypothermia
 Nicotine
 Found in cigarettes (with lots of other bad things)
 Medications to stop smoking:
o Varenicline (Chantix)
 Can smoke but blocks nicotine
 Take after eating with water
o Buproprion (Zyban)
 Antidepressant*
 Take with food
 Blocks withdrawal symptoms
 Anticholinergic S/S and norepinephrine
(nervousness, appetite suppression)
 Do not give with:
 Seizure disorders
 Eating disorders
 Heavy alcohol use
 Monitor BP*****
o Patches:
 Apply to torso and rotate sites
 Keep in place 24 hours
 Adjust dose by cutting patch
 DO NOT SMOKE
 Monitor for:
 Redness
 N/V (too high dose)
o Gum:
 Chew to release nicotine then put in cheek
 DO NOT CHEW LIKE CHEWING GUM
o Nasal Spray
NCLEX REVIEW 53

 Do not inhale
 Localized S/S
o

 Reproduction
o Female
 FSH and LH
 Affects ovaries
 Estrogen and progesterone levels
o When estrogen decreases, progesterone increases to
help maintain lining and prepare for implantation.
o Estrogen
 Helps to protect heart and strengthen bones
 Oral contraceptives
 Prevent pregnancy
 Decrease acne
 Decrease ovarian cysts, dysmenorrhea, and iron deficiency
anemia
 Most oral contraceptives have progestin or estradiol in
name**
o Ethinyl estradiol with norethindrone
 S/S:
 Breast tenderness
 Fatigue
 Headache
 Weight gain
 Photosensitivity
 Cardiovascular!
o Stroke risk!
o DVT!
o PE!
 Monitor for abdominal pain
 Potential sign of ectopic pregnancy
 Progestin-only drugs
o Thickens mucous to prevent implantation
o Risk for prolonged bleeding, amenorrhea
o Can be given for dysfunctional uterine bleeding
o Monitor for:
 Severe chest pain, dyspnea (PE!)
 Photosensitivity
NCLEX REVIEW 54

 Do not give oral contraceptives to patients with:

o Breast cancer
o Cirrhosis
o Major surgery with immobilization
o HTN
o Smoking**
 If accidental pregnancy
o Give within 72 hours:
 Plan B
 Ulipristal
 Pre-eclampsia
 Facial swelling
 Proteinuria
 Edema
 Eclampsia
 Blurred vision
 Seizures
 Uterine contractions
 Oxytocics
o Could cause intracranial hemorrhaging or
arrhythmias in baby
o In mom, could cause uterine rupture, seizures, coma
o D/C if fetal distress occurs on monitor
 Uterine relaxation
 Tocolytics
o Delays labor 24-72 hours
o Allows time to give steroids to help baby’s lungs
develop
o Example:
 Magnesium sulfate
 Terbutaline
 Infertility
 Clomiphene
o Increases release of LH to induce ovulation
 Menopause
 Increased risk for osteoporosis
 HRT
o Monitor for S/S from oral contraceptive S/S
o Also look for decreased libido, depression
o Male
 FSH
NCLEX REVIEW 55

 Sperm production
 LH
 Produces testosterone
o Matures sex organ and secondary sex characteristics
o Can be used to treat breast cancer
o Monitor for:
 Edema
 Liver damage
 Acne
 Irritation (roid rage)
 Elevated cholesterol
 Increased risk for MI
o Don’t give:
 Past MI history
 Past Liver issues
 Hypercalcemia
o If topical testosterone
 Do not let children or women come in
contact with it
 Male infertility
 Can give antiestrogens
o Tamoxifen
 Erectile dysfunction
 Seen with:
o Diabetes
o Kidney disease
o HTN
o Medications
o Depression
 Treat with:
o Sildenafil
 If longer than 4 hour erection, then ED!!
 Biggest S/S:
 Hypotension
 Benign prostatic hypertrophy
 Natural enlargement of prostate
o Increased frequency, hesitancy, nocturia
 Do not give vasoconstrictors!!
o No caffeine, alcohol, alpha agonists
 Give alpha blockers to increase urine flow
o Doxazosin
NCLEX REVIEW 56

o Tamsulosin
o S/S:
 Sexual dysfunction
 Can cause birth defects
 Hypotension
 Bradycardia and bronchoconstriction in
asthma patients
 Takes up to 1 year to work

 Labor stages:
o First stage of labor:
 Early labor phase-onset of contractions until cervix dilated 3 cm
 Lasts 8-12 hours
 Contractions last 30-45 seconds and have 5-30 minutes of rest b/w
o Irregular and get progressively stronger
o Felt in lower back
o Water breaks normally during this time
 Active labor phase-cervix dilates from 3 cm to 7 cm
 Lasts 3-5 hours
 Contractions last 45-60 seconds and 3-5 minutes rest b/w
o Stronger
 Transition phase-cervix dilates from 7 cm to 10 cm
 Lasts 30 minutes to 2 hours
 Contractions last 60-90 seconds with 30 seconds to 2 minute rest
b/w
 Also have chills, N/V, gas, etc.
o Second stage of labor:
 From time of complete dilation until baby is delivered
o Third stage of labor:
 Delivery of placenta
 If placenta not delivered, risk for hemorrhage (monitor for boggy
fundus)
o Complications:
 Placenta previa
 Low implantation of placenta in uterus
 Bleeding always present and bright red*
 Painless*
 Abruptio placentae
 Placenta peels away from uterine wall
 Bleeding sometimes present and dark red*
NCLEX REVIEW 57

 Sharp, stabbing pain*

 For either of these, make sure that in side lying position and NO vaginal
exams
 Umbilical cord prolapse
 Umbilical cord comes out before baby
 Cuts off oxygen and risk for hypoxic brain injury
 Have mom change position and nurse should move cord to prevent
pressure on it.
 Meconium stained fluid
 Fetus was in distress and had bowel movement
 Risk for aspiration for fetus
 Monitor for color of amniotic fluid
NCLEX REVIEW 58

 Fever, musculoskeletal, and inflammation

o Calcium
 Normal: 8.5 to 10.2 (9 is good!)
 Low
 Related to hypoparathyroidism sometimes
 Would mean have high phosphorus
 S/S:
o Tremors
o Chovosck sign
 Cheek twitch
o Trousseu sign
 Hand flexure when BP cuff applied
o Cardiac issues
o Hyperactive deep tendon reflexes
o Seizures
 High
 Related to hyperparathyroidism and chronic renal failure
 Would mean low phosphorus
 S/S:
o Hypoactive deep tendon reflexes
o Stomach upset
o Calcifications throughout body
o Kidney stones
 Foods high in Calcium
 Dark green leafy vegetables
 Soybeans
 Cheese
 Foods high in phosphorus
 Dairy products
 Dark colored sodas
o Osteoporosis
 Related to:
NCLEX REVIEW 59

 Menopause
 High alcohol/caffeine intake
 Anorexia
 Inactivity
 Steroid use
 Treat with:
 Ca supplements and vitamin D
o Calcitriol
 Take with food!
o Monitor for:
 Liver and renal function
 Mg and P
 Bisphosphonates
o Alendronate
o Must sit up 30 minutes after taking
o Can cause:
 Diarrhea
 N/V
 Fractures with long use
 Estrogen receptor modulators
o raloxifene
o Osteomalacia
 Softening of bones
 In kids called rickets!
 Often related to vitamin D deficiency
 S/S:
 Muscle weakness
 Bowlegs
 Bone pain
o Rheumatoid arthritis
 Autoimmune disease
 Pain and stiffness gets worse throughout day
 Symmetric
 See positive RA factor and high ESR
 Give:
 NSAIDs
o Ibuprofen, naproxen, etc.
o Monitor for:
 Bleeding
 GI upset
 Ulcers
NCLEX REVIEW 60

 Corticosteroids
o All have “son” in the name
o Monitor for:
 Infection
 Poor wound healing
 Weight gain (buffalo hump!)
 GI ulcers
 Personality changes
 Antirheumatic drugs
o Always think infection!!!!!
o Hydroxychloroquine (antimalarial drug)
 Infection risk
 Hair loss
 Mental changes**
 Visual field changes**
o Osteoarthritis
 Wear and tear
 Slow onset
 Stiffness in morning improves
 See usually only on one side of body
 Give:
 NSAIDs
 Acetaminophen (only for pain!)
o Monitor liver function!!
 Opioids with acetaminophen
o Monitor for constipation
o Ceiling for amount of acetaminophen given daily
o Gout
 Uric acid buildup
 Red, swollen, puffy joints
 Occurs at night
 Monitor diet to have low purine!
 No organ meats, red wines, anchovies, beans
 Give:
 NSAIDs
 Corticosteroids
 Uricosurics
o Allopurinol (hint: low PURINE)
 S/S:
 Rash
 N/V
 Retinopathy
 Thrombocytopenia**
NCLEX REVIEW 61

o Inflammation!
 Natural response, nonspecific
 Acute vs. Chronic
 S/S:
 Swelling
 Pain
 Warmth
 Redness
 Loss of function
 Paresthesia
 Treat using:
 RICE
o Rest
o Ice
o Compression
o Elevation (above level of heart)
 NSAIDs
o Block breakdown of arachidonic acid to prevent
inflammation
 Aspirin
o Tinnitus****
o GI bleeding
o Headache
o Reyes Syndrome!
 Rash
 Do NOT give aspirin to children unless Kawasaki
disease is present
 Cox 2 inhibitors
o Celecoxib
 Risk for MI and stroke
 Acetaminophen
o Only works for fever and pain!
 Antihistamines
o Anticholinergic*
 Corticosteroids
o Risk for Cushing syndrome
o Infection risk***
o Antibiotics
 Bacteriostatic
 Inhibit growth
 Bacteriocidal
 Kill
 Antibiotic use has led to bacterial resistance and superinfections b/c:
 Not finishing prescriptions
NCLEX REVIEW 62

 Overuse
 Penicillins and Cephalosporins
 Penicillins all have “cillin” in the name
o Hypersensitivity reactions
o Aplastic anemia (infection and bleeding risk!**)
 Cephalosporins all have “cef” in the name
o Similar s/s to penicillin
o Cross sensitivity to penicillin
o Monitor for skin peeling and potential burns!**
 Tetracyclines
 Tetracycline
o S/S:
 Discoloration of teeth
 Birth defects!**
 Photosensitivity
o Do not take with:
 Milk
 Antacids
 Macrolides
 Erythromycin
o N/V
o Diarrhea
o Superinfection
o Do not give with statins!***
 Aminoglycosides
 Gentamicin, tobramycin
o S/S:
 Ototoxic
 Renal toxic
o Monitor peak and trough levels
 Fluoroquinolones
 Ciprofloxin
o S/S
 Dysrhthmias
 Hepatotoxic
 Achilles tendon rupture**
o Do not give with warfarin
 Sulfonamides
 Trimethoprim-sulfamethoxazole
o S/S:
 Urine crystal formation
 Agranulocytosis
 Aplastic anemia
 Photosensitivity
 Hyperkalemia
NCLEX REVIEW 63

o Tuberculosis
 Take drugs 6-12 months
 Use multiple drugs (all affect liver!!**)
 Isoniazid
o Rotate IM sites
o Adverse effects
 Numbness of hands and feet
 Rash
 Fever
 Neurotoxicity
 Paresthesia of feet and hands
 Convulsions
 Optic neuritis
 Dizziness
 Coma
 Memory loss
 Psychoses
o BLACK BOX WARNING
 Hepatotoxicity
 Would appear in first 1 to 3 months
 Monitor for jaundice
 Fatigue
 High liver panel (tested monthly)
 Loss of appetite
 Higher risk in elderly and those with daily alcohol
intake
o Do not give to patients with:
 Liver impairment
o Do not give with:

 Rifampin
 Red-orange urine**
o Fungal infections
 Systemic vs. local
 Usually see systemic in immunosuppressed
 Medications:
 Nystatin
o S/s:
 Skin irritation
 N/V
 Diarrhea
NCLEX REVIEW 64

o Swish and spit vs. swish and swallow

 Amphotericin B
o S/S
 Fever & chills
 N/V
 Phlebitis
 Nephrotoxic***
 Cardiac arrest
 Hypotension
 Bone marrow suppression
 Ototoxic
 Fluconazole
o S/S:
 N/V
 Diarrhea
 Hepatotoxic **
 Blood sugar irregularities
o Antimalarials
 Use these before, during, and 1 week after travel to area with malaria
(vector borne disease)
 Usually messes with liver
 Drugs:
 Chloroquine
o N/V
o CNS toxicity
o Cardiovascular toxicity
 Life threatening arrhythmias***
o Antiprotozoal drugs
 Metronidazole
 S/S:
o N/V
o Headache
o Dry mouth
o Liver toxicity
o Metallic taste in mouth
 DO NOT DRINK ALCOHOL!
 Do not give if suspected pregnancy, skin disorders, metabolic
disorders
o Helminth therapy
 Mebendazole
 S/S:
o Abdominal pain and distension noted
o Aplastic anemia
 Do not give if:
o Preexisting liver disease
NCLEX REVIEW 65

o Younger than 2
 Have them take showers, not baths
o Antivirals
 Difficult to treat viruses
 Mutate rapidly
 HIV
 Therapy begins when CD4 count below 200
 Herpes
 Acyclovir
 Influenza
 Amantadine
o Decreases severity of symptoms
 Do not give vaccine if:
o Egg allergy**
o Hx of Guillian Barre
 Ascending paralysis
 Hepatitis
 For A and B
o Immunoglobulins
 For C
o Interferon
o Ribavirin

NCLEX REVIEW 66

 Respiratory drugs
 5-6 minutes of no breathing can lead to death
 Upper respiratory tract (URT)
o Made up of:
 Nose
 Nasal cavity
 Pharynx
 Paranasal sinuses
o Actions prior to lungs:
 Warms
 Humidifies
 Cleans
 Traps pathogens and particles
 Mucous membrane with ciliated epithelium
o Sweeps pathogens posteriorly=patient swallows when
coughs
 Allergic rhinitis
o “Hay fever”
o Inflammation of nasal mucosa
 Exposure to allergens
 Allergen is anything that is seen as foreign by the body
 Hard to tell what allergen triggered response
 Genetic predisposition in some
 One allergen can sensitize a patient to another allergen
 Common allergens:
o Pollen
o Mold spores
o Dust mites
o Certain foods
o Animal dander
 Worsened by nonallergenic factors:
o Chemical fumes
o Smoke
o Air pollutants
o Not life threatening
 Can experience at specific times of year (I.E. when pollen count high)
 Spring and Fall
 “Seasonal allergies”
 “Perennial” allergic rhinitis
NCLEX REVIEW 67

 Year round due to indoor exposure to allergens

 Do allergy testing
o S/S (like common cold):
 Tearing eyes
 Sneezing
 Nasal congestion
 Postnasal drip
 Itching of throat
 Loss of taste or smell
 Sinusitis
 Chronic cough
 Hoarseness
 Middle ear infection (children)
o Mucosa functions under Autonomic Nervous System
 Sympathetic
 Constricts arterioles, reducing thickness of mucosal layer
 Widens airway
 Sympathomimetic drugs will relieve nasal stuffiness
 Parasympathetic
 Arterioles dilate
 More mucus produced
 Parasympathomimetic drugs will increase nasal stuffiness/drainage
 Mucosa is part of first line of body defense
 Quart of mucus made daily
o Has immunoglobulins
o Defense cells
o Mast cells
 Secrete histamine to trigger inflammation
 Patients with allergic rhinitis have increased mast
cell counts
o Basophils
 Recognize foreign antigens/allergens
 Immediate hypersensitivity reaction:
o Histamine and others released from basophils and mast
cells after binding of IgE antibody
 Sneezing
 Itchy nasal membranes
 Watery eyes
 Delayed hypersensitivity reaction
NCLEX REVIEW 68

o 4-8 hours after initial exposure

o Continuous inflammation
o Chronic nasal congestion
o Goals of allergic rhinitis
 Prevent occurrence
 “Preventers”
o Prophylaxis
 Antihistamines
 Intranasal corticosteroids
 Mast cell stabilizers
 Relieve symptoms
 “Relievers”
o Provide immediate, temporary relief
 Oral and intranasal decongestants
 Sympathomimetic drugs
 Educate patient:
 Identify allergens
 Remove pets from inside
 Clean moldy areas
 Use microfilters on AC units
 Cleaning dust mites from furniture
 H1-Receptor Antagonists/Antihistamines and Mast Cell Stabilizers
o Block H1 receptors
o OTC drugs for:
 Allergies
 Motion sickness
 Nausea
 Must take prior to onset of symptoms
 Depresses neurons in vestibular apparatus in inner ear
 Dramamine
 Antivert
 Insomnia
 Antihistamines included in OTC sleep aids
 Use for two weeks or less so not develop tolerance
 Parkinson’s disease
 For tremors and other S/S
 Urticaria/skin rashes
 Hives
 Caused by histamine release
NCLEX REVIEW 69

o Histamine:
 Chemical mediator of inflammation
 Released from mast cells and basophils
 Causes of binding to H1 receptors:
 Itching
 Increased mucus secretion
 Nasal congestion
 Bronchoconstriction (anaphylaxis)
 Edema (anaphylaxis)
 Hypotension (anaphylaxis)
 H2 receptors relate to peptic ulcers
o Antihistamines
 Selectively block histamine from reaching H1 receptors
 Relieves allergic symptoms
 Therapeutic use:
 Allergies
o Sneezing
o Runny nose
o Itching eyes, nose, throat
 Most effective when taken prophylactically to prevent symptoms
 Prior to allergy season!!
 Limited use in stopping current episodes
 Not as effective with long term use
 Anticholinergic
 Drying of mucous membranes
o Less nasal congestion/tearing
 Adverse effects:
 Drowsiness (tolerance over time)
 Sedation
 CNS stimulation in some patients
o Insomnia
o Nervousness
o Tremors
 Anticholinergic effects:
o Dry mouth
o Urinary hesitancy
 Use cautiously with:
 Alcohol (amplify sedation)
 CNS depressants (amplify sedation)
NCLEX REVIEW 70

 Most given PO/intranasal/intraocular

 First and second generation
 First generation:
o Benadryl
 Second generation:
o Certirizine (Zyrtec)
o Loratadine (Claritin)
o Fexofenadine (Allegra)
o Prototype: Diphenhydramine (Benadryl)-First generation
 Treats minor allergy and cold symptoms
 Also can be used for rashes
 IV/IM forms for severe allergic reactions
 Increased risk for anaphylactic shock if given IV
o Give at rate of 25 mg/min
 With IM, give in deep muscle
 Adverse effects:
 Drowsiness (tolerance with long term use)
 Paradoxical CNS stimulation (especially in children)
 Anticholinergic effects
o Tachycardia
o Hypotension
o Dry mouth
 Photosensitivity
 Do not give to patients with:
 Prostatic hypertrophy
 Narrow-angle glaucoma
 GI obstruction
 Asthma (cautiously)
 Hyperthyroidism (cautiously)
 Do not give with:
 CNS depressants (increased sedation)
 Other OTC cold medications (increased anticholinergic effect)
 MAO-I (hypertensive crisis)
 Herbane (increased anticholinergic effect
 The drug must be stopped four days prior to skin allergy test
 False negatives otherwise
 Intranasal corticosteroids
o “Glucocorticoids”
NCLEX REVIEW 71

o Most have “son” in the name

o Used for perennial allergic rhinitis
o No serious side effects (unlike systemic corticosteroids)
 Burning sensation in nose after spraying
 Excessive drying of nasal passage
 Epistaxis (nose bleed)
o Works by:
 Decreasing secretion of inflammatory mediators
 Reducing tissue edema
 Vasoconstriction
o Given by metered-spray device
 Consistent dose per spray
o Do not have immediate benefits like sympathomimetic drugs
 May take one to three weeks to work
 Best if taken prior to an episode as prophylaxis
o Prototype: Fluticasone (Flonase, Veramyst)
 For seasonal allergies
 Two sprays to each nostril, 2x daily
 Over time down to one dose daily
 Decreases local inflammation to decrease stuffy nose
 Veramyst used for seasonal and perennial allergic rhinitis
 Educate patient on following directions on label
 Adverse effects:
 Only when patient accidentally swallows medication
o Leads to systemic effects (hypercorticism)
 Occasional epistaxis
 Do not give to patients with:
 Hypersensitivity to drug
 Active infection (as corticosteroids mask it)
 Do not give with:
 Intranasal decongestant (increases bleeding risk in nose)
 Ritonavir (increases plasma levels of fluticasone)
 Licorice (increases effects of drug)
 Mast cell stabilizer
o Cromolyn (NasalCrom)
o Inhibits release of histamine from mast cells
o Prophylaxis
 Decongestants
o Relieve nasal congestion
NCLEX REVIEW 72

o Ends in either “zoline” or “ephrine”

o Clear nasal passages prior to administration of nasal spray (blow your nose)
o PO/intranasal
 Intranasal can work within minutes
o Usually combined with antihistamines b/c only relieve nasal congestion
o Sympathomimetic drugs
 Alpha-adrenergic activity
o Intranasal sympathomimetics
 Few systemic effects
 Adverse effect:
 Rebound congestion
o Worsening congestion and hypersecretion of mucus when
medication wears off
o Leads to increased drug use
o Should not use decongestants longer than 3 to 5 days
o If tolerance develops, switch to intranasal corticosteroids
o PO sympathomimetic drugs
 No rebound congestion
 Slower onset of action
 Less effective with severe congestion
 Greater chance for systemic effects
 HTN
 CNS stimulation
 I.E. Pseudoephedrine (Sudafed)
 Adverse effects:
o Nervousness
o Insomnia
o Headache
o Dry mouth
o Prototype: Oxymetazoline
 Sympathomimetic drug
 Dries mucous membranes
 Onset in minutes
 Can last 10 or more hours
 Given via metered-spray dose
 Can be given as eye drops for tearing
 Teach patient to wash hands after administration
 Anisocoria (blurred vision/ unequal pupils) may occur
 Adverse effects:
NCLEX REVIEW 73

 Rebound congestion if used longer than 3-5 days

 Stinging/dryness of nasal mucosa
 Do not give to patients with:
 Thyroid disorders
 HTN
 Diabetes
 Heart disease
 Do not use with:
 St. John’s wort or other drugs with similar MAO-I properties
 Common Cold
o Viral infection of URT
o Self-limiting
 No cure/prevention for colds
o Antihistamines and decongestants are used
o Antitussives
 Reduce cough reflex
 Especially with dry, hacking, nonproductive coughs
 Swallow without water
 After 30-60 minutes, increase fluid intake
 Two classes:
 Opioids
o Raise cough threshold in CNS
o Need only small doses of opioids
o Classified as schedule III, IV, V drugs
 May lead to respiratory depression
 Caution with patients with:
o Asthma
o I.E. Codeine and Hydrocodone
 Non-opioids
o Prototype: Dextromethorphan
 OTC cold and flu medications
 Rapid onset of action (15-30 minutes)
 Raises cough threshold in CNS (medulla)
 Avoid smoking or other fume inhalation
 Decreases drug effectiveness
 Adverse effects in large doses:
 Hallucinations
 Slurred speech
 Dizziness
NCLEX REVIEW 74

 Drowsiness
 GI upset
 Euphoria
 Lack of motor coordination
 Seizures
 Coma
 Do not give to patients with:
 Chronic cough from excessive bronchial
secretions
o Asthma
o Smoking
o Emphysema
 Do not give with:
 MAO-I (excitation, hypotension,
hyperpyrexia)
 CNS depressants (Sedation)
 Grapefruit juice (Drug toxicity)
 Educate on potential for abuse in younger
population
o Benzonatate (Tessalon)
 Suppresses the cough reflex
 Anesthetizes stretch receptors in lungs
 If chewed:
 Numbing of mouth and pharynx
 Adverse effects:
 Sedation
 Nausea
 Headache
 Dizziness
 Benylin
 Children’s anti-cough syrup
 Helps to relieve dry coughs in children under five
 Contains glycerol
 Consult with doctor if not improve in three days
 Consult doctor if:
o Child has allergic reaction to medication
o Child is under three months
o Child is fructose intolerant
 Adverse effects:
NCLEX REVIEW 75

o Mild laxative
 This is not meant for adults!
o Expectorants and Mucolytics
 Increase bronchial secretions (expectorants)
 Syrups should be given with full glass of liquid and increased fluid
intake throughout day
 Guaifenesin (Mucinex)
o Reduce the thickness/viscosity of bronchial secretions
o Increases mucus flow and excretion via cough
o Best for dry, nonproductive coughs
 Still works for productive coughs
o Do not give to children under 6 years if not prescribed
 Loosen thick bronchial secretions (mucolytics)
 Acetylcysteine (Mucomyst)
o Directly loosens thick, viscous secretions
 Breaks down chemical structure of mucus
 Makes it thinner and easier to excrete
o Inhaled/IV
 IV dose given as overdose antidote for
acetaminophen toxicity
o Prescription medication
o Used for patients with:
 Cystic fibrosis
 Chronic bronchitis
o Adverse effects:
 Bronchospasm
 Smells like rotten eggs
 Severe nausea and vomiting (no kidding)
o Horehound
 Expectorant action with colds
 Available as cough drop
 Can be used for:
 Asthma
 Bronchitis
 Whooping cough
 Infections
o TB
 Bowel disorders
 Jaundice
NCLEX REVIEW 76

 Wound healing
o Teach patient to:
 Increase fluid intake to help mobilize mucus
 Monitor pulse and BP
 Avoid/eliminate alcohol
 Never take with alcohol!!
 Not keep medications at bedside
 Prevents overdosage if drowsy
 Clear nasal passages first
 Then give spray
 Wait 5-10 minutes before next spray
 Spit out excess drainage in mouth
 Limit use to 3-5 days
 Importance of using single-symptom preparations
 If contain acetaminophen, make sure to take only prescribed dose
o Monitor the elderly for dizziness/drowsiness
 Increases fall risk!
o Report to health care provider if:
 Symptoms worsen
 Fever present
 Dizziness
 Palpitations
 Syncope
 Change in severity/frequency of cough
 SOB with cough
 Chest pain with cough
 Color/thickness/quantity of mucus
 Altered LOC
 Any visual changes
 Any eye pain
 Inability to void
NCLEX REVIEW 77

 Drugs for Asthma

 Lower respiratory system
o Primary function
 Bring O2 to body
 Take CO2 out of body
 Known as respiration
o Ventilation
 Process of moving air into and out of lungs
 As diaphragm contracts and lowers, negative pressure
o Inspiration
 Diaphragm relaxes and air leaves lungs passively
o Expiration
 Mechanical process
 12-18 times/minute in adults
 Rate may be affected by:
o Emotions
o Fever
o Stress
o pH of blood
o Certain medications
o Ends in alveoli
 No smooth muscle
 Capillaries
 Gas exchange location
o Perfusion
 Blood flow through the lungs
 Bronchioles
o Muscular, elastic muscle
o Contracts or relaxes
 Bronchodilation
 Opens lumen
 Increases oxygen supply to tissues
 Bronchoconstriction
 Closes lumen
 Decreased airflow
NCLEX REVIEW 78

o Contraction/relaxation regulated by
 Sympathetic branch:
 Activates beta2-adrenergic receptors
o Relaxation of smooth muscle
o Bronchodilation
 Medications:
o Bronchodilators
 Parasympathetic branch:
 Bronchoconstriction
 Medications:
o May cause labored breathing and SOB
 Administration of Pulmonary Drugs via Inhalation
o Rapid delivery
o Aerosol
 Suspension of minute liquid droplets or fine solid particles suspended in
gas
 Advantages:
 Delivers drugs to immediate site of action
o Decreases systemic effects
 Immediate relief for bronchospasms
o When bronchioles rapidly contract and limit air supply
 Also to loosen thick mucus in bronchioles
 Disadvantages:
 May still produce systemic effects
o Some drug absorption across capillary membrane
 I.E. Laughing gas can cause CNS depression via
inhalation route
 Precise dose given hard to measure
o Depends on:
 Patient’s breathing pattern
 Proper use of inhaler
 Generally, only 10-50 % of drug reaches lower respiratory tract
 Swallowing excess medication in mouth can cause systemic effects
if absorbed in GI tract
o Rinse mouth out to avoid absorption through oral mucosa
 Several devices to administer inhalants
 Nebulizer
o Small machine that vaporizes liquid medication into fine
mist to be inhaled
NCLEX REVIEW 79

 Handheld device
 Face mask
 Dry powder inhaler (DPI)
o Small device activated by inhalation to deliver powder to
bronchial tree
o Turbuhaler
o Rotahaler
 Metered-dose inhaler (MDI)
o Propellant delivers measured dose with each breath
o Time inhalations to match puffs
 How to use an inhaler:
o Use spacer if instructed b/w MDI and mouth
o Shake inhaler/load with tablet or powder
o If using bronchodilator/corticosteroid inhalers
 Use bronchodilator first
 Wait 5-10 minutes
 Use corticosteroid so that drug goes deeper
o Rinse mouth after using inhaler
o Rinse spacer and inhaler in water daily and air dry
 Asthma
o Chronic pulmonary disease
 Inflammation
 Bronchospasm
o Drugs given to:
 Decrease frequency (prophylaxis)
 Stop current episode
o Fun facts:
 African American women highest asthma mortality rate
 Asthma is most common chronic childhood disease
 It affects more grown women than men
 With children, it affects more boys than girls
o If new onset asthma
 Assess for any recent changes in:
 Diet
 Soaps, etc.
o Always obtain baseline vital signs
o Have patient increase fluid intake to assist with mobilization of mucus
o Other nonpharmacological interventions for asthma/COPD:
 Consume small, frequent calorie and nutrient-dense meals
NCLEX REVIEW 80

 Adequate rest periods b/w eating and activities

 Decrease room temperature while sleeping
 Reduce exposure to allergens
 Immediately report any changes in:
 Appetite
 Inability to maintain normal intake
 Inadequate sleep periods
 Inability to carry out ADLs
o Usually considered a pediatric disease
o S/S:
 Acute bronchospasm and constriction
 SOB
 Coughing
 Gasping for air
 Inflammatory response
 Triggers histamine
o Increases mucus and edema of airways
o S/S lead to airway obstruction
o Patient can have acute or chronic S/S
 Periods between symptoms may last days to weeks to months
 Some episodes triggered by certain environmental factors:
 Air pollutants
o Tobacco smoke
o Ozone
o Nitrous oxides
o Fumes from cleaning fluids
o Burning leaves
 Allergens
o Pollen
o Animal dander
o Household dust
o Mold
 Chemicals and foods
o Drugs
 Aspirin
 Ibuprofen
 Beta blockers
o Sulfite preservatives in foods
o Food and condiments
NCLEX REVIEW 81

 Nuts
 MSG
 Shellfish
 Dairy products
o Respiratory infections
 Bacterial, fungal, viral
o Stress
 Exercise in dry, cold climates
 “exercise-induced asthma”
 Status asthmaticus
o Severe, prolonged asthma
 Unresponsive to drugs
 Respiratory failure may result
o Goals of therapy:
 Terminate existing attacks
 Reduce frequency of attacks
 Two classes:
 Quick-relief medications:
o Short/intermediate-acting beta2-adrenergic agonist
(SABAs)
 Bronchodilator
 Preferred for relief of acute symptoms
o Anticholinergics
 Bronchodilator
 Alternative for those who cannot take SABAs
o Systemic corticosteroids
 Anti-inflammatory
 Not rapid
 PO for short periods to reduce frequency of acute
episodes
 Long-acting medications
o Inhaled corticosteroids
 Anti-inflammatory
 Preferred Long-term asthma management
 PO for severe, persistent asthma
o Mast cell stabilizers
 Anti-inflammatory
 For mild, persistent asthma or exercise-induced
o Leukotriene modifiers
 Anti-inflammatory
NCLEX REVIEW 82

Mild, persistent asthma or adjunct with inhaled

corticosteroids
o Long-acting beta2-adrenergic agonist
 Bronchodilator
 Used with inhaled corticosteroids for prophylaxis
 Moderate to severe persistent asthma
o Methylxanthines
 Bronchodilator
 Used with inhaled corticosteroids for prophylaxis
 Mild to moderate persistent asthma
o Immunomodulators
 Monoclonal antibody
 Adjunct therapy for patients with allergies
 Severe persistent asthma
 Bronchodilators
o Beta-Adrenergic Agonists
 “Beta agonists”
 First line for acute bronchoconstriction
 No anti-inflammatory function
 If chronic asthmas, other medications are needed to control this
 End in “terol”
 Activate sympathetic nervous system
 Relax smooth muscle
 Beta1 receptors found in:
o Heart
 Beta2 receptors found in:
o Lung
o Uterus
o Etc.
 Beta agonists that activate Beta1 and Beta2 receptors-nonselective
 I.E. Epinephrine
 Isoproterenol
 Beta agonists that activate only Beta2 receptors-selective
 Fewer cardiac S/S
 Divided based on duration of action
o Short-acting drugs:
 Pirbuterol (Maxair)
 “Rescue drugs”
 Effects last 2-6 hours
NCLEX REVIEW 83

 PRN drugs
o Intermediate duration
 Effects last 8 hours
o Long acting drugs (LABAs)
 12 hour duration
 Slow onset of action
 Salmeterol (Serevent)
 BLACK BOX
 Increased deaths
o People tried to take a LABA instead
of SABA during acute episode
 Must educate patient to use with other drugs:
 I.E. inhaled corticosteroids
 For those with severe asthma that needs
more than one drug to control
 Available:
o PO
 Longer duration of action
 More systemic effects
 Activation of Beta1 receptors on heart
o Dysrhythmias
o MI
o Death
 Tolerance develops over time
 Higher doses needed
 As doses keep getting higher and more
frequent, call provider!
o Inhaled (most common for respiratory conditions)
 Minimal systemic effects
o Parenteral
 General adverse effects:
o Headache
o Dizziness
o Tremor
o Nervousness
o Throat irritation
o Tolerance
o Tachycardia
o Dysrhythmias
NCLEX REVIEW 84

o Hypokalemia
o Hyperglycemia
o Paradoxical bronchoconstriction
o Increased risk for asthma-related death
 Prototype: Albuterol (Proventil, Ventolin, VoSpire)
 SABA
 Rapid onset
 Terminates occurring episode
 Bronchodilator
 Increases mucus drainage
 Inhibits release of inflammatory particles from mast cells
 If given 15-30 minutes before exercise
o Prevents exercise-induced bronchospasm
 NOT FOR ASTHMA PROPHYLAXIS
 Teach patient proper use of inhaler and actuator
 Adverse effects:
o Palpitations
o Headaches
o Throat irritation
o Tremors
o Nervousness
o Restlessness
o Tachycardia
o Insomnia
o Dry mouth
o Chest pain
o Paradoxical bronchospasm
o Anaphylaxis
 Do not give to patients with:
o Hx of cardiac disease
o Hx of HTN
 Do not give with:
o Beta blockers (inhibits bronchodilation)
o MAO-Is (within 14 days of ending MAO-I therapy)
o Caffeine (nervousness, tremor, palpitations)
 May cause decrease in the following lab:
o Potassium
 For overdose:
NCLEX REVIEW 85

o Beta blocker for cardiac S/S

o Anticholinergic drugs
 End in “ium”
 Alternative bronchodilators for those who cannot tolerate beta agonists
 Block parasympathetic response
 Three anticholinergic drugs approved for asthma via inhalation:
 Prototype: Ipratropium (Atrovent)
o For COPD and asthma
o Slower onset
o Used as alternative to SABA
o For patients with severe asthma episodes
o Inhibits nasal secretions
 No decongestion effect
o Only give for 3 weeks or less
o Educate patient on how to use MDI
 Have patient wait 2-3 minutes between dosages
 Avoid contact with eyes (blurred vision)
o Adverse effects:
 Few systemic effects
 Irritation of upper respiratory tract
 Cough
 Drying of nasal mucosa-nose bleeds
 Hoarseness
 Bitter taste (rinse mouth out)
o Do not give to patients with:
 Hypersensitivity to soya lecithin or soybeans and
peanuts
 Propellant in inhaler
o Do not give with:
 Other anticholinergic drugs (increased effect)
o Overdose does not occur
 Aclidinium (Tudorza Pressair)
o For COPD
 Tiotropium (Spiriva)
o Long-term maintenance for asthma
o Prophylaxis for COPD
 Chronic bronchitis
 Emphysema
NCLEX REVIEW 86

 Combivent (combination ipratropium and albuterol) in MDI

canister
o First line drug for treating bronchospasms from COPD
 Bronchitis
 Emphysema
 Off label use for asthma
 Common adverse effects:
o Dry mouth
o GI distress
o Headache
o Anxiety
o Pharyngitis
o Methylxanthines
 Long term management of persistent asthma
 Has to be unresponsive to beta agonists or inhaled corticosteroids
 Chemical equivalents to caffeine!
 Narrow safety margin
 Given PO or IV (not inhaled)
 End in “phylline”
 Aminophylline (Truphylline)
 Theophylline (Theo-Dur)
 Adverse effects:
 Nervousness
 Tremors
 Dizziness
 Headache
 Nausea
 Vomiting
 Anorexia
 Tachycardia
 Dysrhythmias
 Hypotension
 Seizures
 Circulatory failure
 Respiratory depression
 Anti-inflammatory drugs for Asthma
o Corticosteroids
 Inhaled
 Long term prophylaxis
NCLEX REVIEW 87

 Absorbed slowly, so little systemic S/S noted

 Suppress inflammation w/o major adverse effects
 4-8 weeks for maximum effect
 LABA may be given with it for added effect
 Take once daily
 Adverse effects:
o Hoarseness
o Oropharyngeal candidiasis
o With prolonged therapy, bone physiology changes
 Do tests for osteoporosis!
 Not effective at stopping current episode
o Carry short-acting inhaler medication for that
 Prototype: Beclomethasone (Beconase AQ, Qvar, Qnasl)
o Anti-inflammatory drug
o Inhalation for asthma/nasal spray for allergic rhinitis
 With nasal spray:
 Use to prevent nasal polyp formation
following surgery
o Long-term management of persistent asthma in children
and adults
o 3-4 weeks of therapy to see benefits
o Does not stop current asthma attacks!
o Do not substitute oral inhalation and nasal spray
o Adverse effects:
 Few systemic effects
 Monitor for corticosteroid toxicity
 Hoarseness
 Dry mouth
 Changes in taste
 Cataracts in adults
 Growth retardation in children
 Fungal infections in throat
o Do not give to patients with:
 Pediatric patients (cautiously)
 Active infection (masks S/S)
 PO
 Short-term for acute severe and unstable asthma
 Systemic
 5-7 days of therapy
NCLEX REVIEW 88

o If taken longer than 10 days, significant systemic effects

 Adrenal gland atrophy
 Peptic ulcers
 Hyperglycemia
 Growth retardation in children
 With prolonged therapy, bone physiology changes
 Afterwards, go to inhaled therapy
 End in “sone” or “nide”
 “Glucocorticoids”
 Most potent anti-inflammatory drugs
 Increases production of anti-inflammatory mediators
 Decrease mucus production and edema
 Also sensitize bronchial smooth muscle to beta-agonist stimulation
 Reduce bronchial hyper-responsiveness to allergens
o Leukotriene modifiers
 For inflammation and bronchoconstriction (indirectly)
 Do not use to stop occurring asthma attacks!!!!
 Leukotrienes
 Mediators of immune response with allergic/asthmatic reactions
 Made by mast cells, neutrophils, basophils, eosinophil
 Cause:
o Edema
o Inflammation
o Bronchoconstriction
 Most end in “ast”
 Drugs:
 Montelukast (Singulair)
o Block leukotriene receptors
o Can take up to a week to become effective
 Roflumilast (Daliresp)
 Zilueton (Zyflo CR)
o Blocks lipoxygenase
 Inhibits synthesis of leukotrienes
o Rapid onset (2 hours)
 Prototype: Zafirlukast (Accolate)
o Anti-inflammatory drug
o Prophylaxis for chronic asthma
 Not as effective as corticosteroids
o Prevents airway edema and inflammation
NCLEX REVIEW 89

 Blocks leukotriene receptors

o PO
o Long onset of action
 Can take up to a week to become effective
o DO NOT USE TO TERMINATE OCCURRING
ATTACKS
o Adverse effects:
 Headache
 Cough
 Nasal congestion
 Infections (especially if older than 65)
 Nausea
 Diarrhea
 Throat pain
 Weight loss
 Liver toxicity
 Psychiatric problems
o Do not give to patients with:
 Pre-existing liver impairment
o Do not give with:
 Warfarin (increases PT time)
 Erythromycin (decreases level of asthma drug)
 Aspirin (increase levels of asthma drug)
 Food (take on empty stomach!)
o May increase:
 ALT
o Mast Cell Stabilizers
 Prophylaxis of asthma
 Less effective than corticosteroids
 Inhibit release of histamine form mast cells
 Prevents inflammation
 Prevents asthma attack
 Take medications daily
 Cannot stop occurring attacks!!
 Maximum therapeutic effect may take several weeks
 Medications:
 Cromolyn (Intal)
o Short half life (4-6 times daily dosing)
o Can be given:
NCLEX REVIEW 90

 MDI (asthma prophylaxis)

 Nebulizer (asthma prophylaxis)
 Intranasal (Nasalcrom)
 Seasonal allergies
 Ophthalmic (Crolom)
 Allergic disorders in eyes
 PO (Gastrocrom)
 For systemic mastocytosis
o Excessive numbers of mast cells
 Off label:
o Ulcerative colitis
o Food allergy prophylaxis
 Adverse effects:
 Stinging/burning of nasal mucosa
 Irritation of throat
 Nasal congestion
 Bronchospasm
 Anaphylaxis
 Nedocromil (Tilade)
o MDI
o Longer half life
o Adverse effects:
 Bitter taste in mouth
o Eye version (Alocril) for allergic conjunctivitis
o Monoclonal antibodies
 Attach to specific receptors on target cells/molecules
 On IgE
o Prevents inflammation and decreases body’s response to
allergens that trigger asthma
 For moderate to severe, persistent asthma and allergic rhinitis
 For patients 12 years and older
 Asthma unable to be managed by inhaled corticosteroids
 Given SQ every 2-4 weeks
 Adverse effects:
 Anaphylaxis
 Bleeding
 Dysmenorrhea
 Rash
 Headache
NCLEX REVIEW 91

 Viral infections
 Omalizumab (Xolair)
 Chronic Obstructive Pulmonary Disease
o Progressive pulmonary disorder
 Chronic and recurrent airflow obstruction
o Mostly caused by:
 Asthma
 Air pollution
 Chronic bronchitis
 Excessive mucus produced in lower respiratory tract
o Airway becomes occluded
 Dyspnea and coughing occur
o Early S/S:
 Productive cough on awakening
 Wheezing
 Decreased exercise tolerance
 Often have comorbidities
o HF
o HTN
 Strongly associated with tobacco smoking
 Strongly associated with air pollution
 Emphysema
 Terminal stage of COPD
o Bronchioles lose elasticity
 Alveoli dilate to allow for increased air flow
 Extreme dyspnea
 Strongly associated with tobacco smoking
 Strongly associated with air pollution
o Major cause of death/disability
o Goals of therapy:
 Relieve symptoms
 Avoid complciations
o Medications:
 Bronchodilators
 Ipratropium (Atrovent)
 Beta2 agonist (SABA and LABA)
 Inhaled corticosteroids
 Mucolytics and expectorants
 Oxygen therapy
NCLEX REVIEW 92

 Antibiotics for pulmonary infections

 Roflumilast (Daliresp)
 Anti-inflammatory drug
 Inhibits phosphodiesterase-4
o Airway expansion
 Prophylaxis, not immediate solution
 Do not give COPD patients:
 Beta blocker drugs
 Any drugs that cause bronchoconstriction
 Respiratory depressants
o Opioids
o Barbiturates
 Teach COPD patients:
 Smoking cessation!!
 Proper inhaler use
o Problems associated with aging
 Cognitive ability
 Dexterirty
 Tremors
 Visual/hearing impairment
 Disease-based problems
o Other problems:
 Difficult instructions
 Several devices
 Respiratory distress syndrome
o In premature infants
o Lungs not producing surfactant
 Alveoli collapse
o Give prophylactic or rescue medications intratracheal every 4-6 hours
 Calfactant
 Beractant
 Poractant alpha
 Lucinactant
NCLEX REVIEW 93

 Fluid & Electrolytes/Acid-base balance

o Majority of body is water
 Water always moves to dilute the solute!!***
o Intake should be around 2,500 mL/day
o Output:
 Kidneys (urine)
 Lungs (evaporation)
 Skin (evaporation)
 Feces
o ADH and RASS help with regulation of osmolality
 Osmolality regularly 275 to 295 mOsm/kg
o Tonicity
 Isotonic
 Solute amount equal to solvent amount
 0.9% NS
 Albumin
o Used for hypoproteinemia
 Hypotonic
 Less solute than solvent (water)
 0.45% NS
 Hypertonic
NCLEX REVIEW 94

 More solute than solvent (Water)

 3% NS
 Usually only see with high ICP
o Dehydration
 Decreased extracellular fluid volume
 Leads to concentrated electrolytes
 High Na=Neuro!
 High K=Cardiac!
 Can occur from:
 Vomiting
 Diarrhea
 Excessive sweating
 Severe burns
 Hemorrhage
 Excessive urination
 Can go into hypovolemic shock
 Decreased cardiac output
 Increasing afterload to compensate with vasoconstriction
 Give fluids to resuscitate patient and prevent circulatory collapse
o Monitor for signs of fluid overload
o Electrolyte imbalances
 Na (most abundant extracellular cation: 135-145)
 Hypernatremia
o Caused by:
 Kidney disease
 Dehydration
 Excessive salt intake
 High doses of steroids
o S/S:
 Thirst
 Fatigue
 NEURO!!!
o Modified through:
 Decrease sodium in diet
 Hypotonic IV administration
 Diuretics (potassium sparing)
 Hyponatremia
o Caused by:
 Excessive ADH (retains water!)
 Hypotonic IV solutions
 Sodium loss through burns, sweating, fever,
vomiting, diuretics
NCLEX REVIEW 95

o S/S:
 N/V
 Altered LOC
 Seizures
 NEURO!
 Potassium (most abundant intracellular cation: 3.5-5.0)
 Hyperkalemia
o Caused by:
 High potassium intake
 Papayas
 Bananas
 Supplements
 Potassium sparing diuretics
 Chronic renal disease
 ACE inhibitors
o S/S:
 Cardiac!****
 Tall tented T waves on EKG
 Ventricular fibrillation
 Death
 Abdominal discomfort
 Diarrhea
 Muscle weakness
o Treated through:
 Avoiding high K foods
 Administering Glucose and Insulin!
 Administering sodium bicarbonate
 Giving Kayexelate
 Hypokalemia
o Caused by:
 Loop or thiazide diuretics
 Digoxin
 N/V, diarrhea
o S/S:
 Cardiac!***
 Muscle weakness
 Anorexia
o Treated through:
 Eating more foods with K
 Supplements
 Chloride (major extracellular anion: 98 to 108)
 Usually bound with salt
NCLEX REVIEW 96

 Hyperchloremia
o Caused by:
 Kidney disease
 Diarrhea
 Hyperparathyroidism
o S/S:
 Dehydration
 Hyperglycemia
 HTN
 Tachypnea/Kussmaul breathing
 NEURO
o Treatment:
 Fluid resuscitation
 Sodium bicarbonate
 LR
 Low sodium diet
 Hypochloremia
o Caused by:
 Excessive urination/sweating
 Vomiting
 Kidney disease
 Cystic fibrosis
o S/S:
 Dehydration
 Hypertonicity/spasticity
 Shallow depressed breathing**
 Hyponatremia (NEURO!)
o Treatment:
 0.9% NS or 0.45% NS
 Increased dietary intake of Na and K
 Magnesium (1.5-2.5)
 Get through:
o Dark green leafy vegetables
o Whole grain bread
 Hypomagnesemia
o Caused by:
 Alcoholism
 DKA
 Kidney disease
 Pancreatitis
 Hypoparathyroidism
o S/S:
NCLEX REVIEW 97

 Low Ca
 Muscle weakness
 Tremors
 HTN
 Altered LOC
 Hypermagnesemia
o Caused by:
 Dehydration
 Addison’s disease
 Hyperparathyroidism
 Kidney failure
 Hypothyroidism
o S/S:
 Depressed respirations**
 Seen with OB patients given this for preterm
labor
 Decreased reflexes
 Confusion
 Constipation
 Phosphorus (major intracellular anion: 2.5-4.5)
 High phosphorus shows symptoms of low Ca
 Low phosphorus shows symptoms of high Ca
o Acid-base balance
 Normal pH: 7.35-7.45
 Based on amount of hydrogen ions
 Less than 7.35 is acidotic
 Greater than 7.45 is alkalotic
 CO2: 35-45
 Bicarbonate: 22-28
 Major base buffer
 PO2: 80-100
 ROMEO (write out everything, including normal values, and put up or
down arrows next to each abnormal value to show answer based on
ROMEO)
 Respiratory
 Opposite
 Metabolic
 Equal
 Oxygen (are they hypoxic?)
 Types of acid-base imbalances
 (Takes longer for metabolic (kidneys) to compensate; respiratory
(lungs) are for fast compensation)
NCLEX REVIEW 98

 Respiratory acidosis
o High CO2
o Hypoventilation
 Usually related to drug overdose
 Respiratory alkalosis
o Low CO2
o Hyperventilation
 Blowing off CO2
 Have them breath into a paper bag
 Metabolic acidosis
o High hydrogen ions, low bicarbonate
o Can be related to:
 Kidney failure
 DKA
 Diarrhea
 Rhabdomyolysis
o Compensated for in DKA with:
 Kussmaul respirations
 Deep, fast breathing to make respiratory
alkalosis
 Metabolic alkalosis
o Low hydrogen ions, high bicarbonate
o Can be related to:
 Excessive vomiting/suctioning
o Compensated through respiratory acidosis
NCLEX REVIEW 99

 Endocrine
o Hypothalamus=master gland
 Regulates via negative feedback to allow for homeostasis
 Releases hormones like:
 Gonadotropin releasing hormone
 Thyroid releasing hormone
o Pituitary gland
 Receives hormones from hypothalamus and stimulates release of other
hormones
 Anterior pituitary:
 Growth hormone (GH)
o Important for children’s growth
o Highest at night
 Why important to get deep sleep (stages 3 and 4)
o Deficiency:
 Can give SQ growth hormones to children nightly
before puberty to help gain some height
 Monitor for infection risk
NCLEX REVIEW 100

 Once growth plates close, not effective

 Monitor growth trends and counsel for self-esteem
issues
o Excessive:
 Acromegaly
 Excessive growth hormone that occurs after
growth plates have closed, resulting in facial
and hand and feet deformities.
o Usually related to a tumor
 Gigantism
 Excessive growth hormone that is secreted
before growth plates close
o Proportionate
 For both, can use sandostatin, which is a growth
hormone antagonist
 Adrenocorticotropic hormone (ACTH)
o Leads to secretion of cortisol from adrenal cortex
o Aldosterone secretion
 Based on RAAS
 Hyperaldosteronism
 High levels of Na in body, low K
 Think of neuro and cardiac complications
 High water retention
o Cortisol is the stress hormone!**
 Increases glucose in body to give energy for fight or
flight (so hyperglycemia)
 Gluconeogenesis
o Creating glucose from protein and
fats
 Glycogenolysis
o Breaking down glycogen into
glucose
 Addison’s disease
 Chronic deficiency of cortisol and
aldosterone
 S/S:
o High K (cardiac!)
o Low Na (neuro!)
o Brown skin discoloration
o Tremors
o Pallor
NCLEX REVIEW 101

o Decreased LOC
 Treat by replacing cortisol and aldosterone
 Cushing’s disease
 Excessive cortisol and aldosterone secretion
o Could be related to drugs, tumor, etc.
 S/S:
o Weight gain
 Possible fluid overload S/S
o High Na (so Neuro)
o Low K (so Cardiac)
o Poor wound healing
o Mood swings
 Treat possibly through removing adrenal
glands
 Thyroid stimulating hormone (TSH)
o Activates thyroid to lead to release of T3 and T4
 Helps with basal metabolic rate
o Need iodine!!***
 Get from:
 Soy sauce
 Fish
 Salt
o Hypothyroidism (superman when Krypton and all family
destroyed, or like depression)
 Decreased metabolic rate
 S/S:
 Bradycardia
 Decreased LOC
o Coma!
 Non pitting edema
 Dry, course hair
 Treat using:
 Levothyroxine
o Worry about S/S of hyperthyroidism
o Hyperthyroidism (superman saving Lois Lane, or mania)
 A.k.a. Graves Disease
 Increased metabolic rate
 S/S:
 Exophthalmos (bulging eyes)
 Tachycardic
 Tremors
NCLEX REVIEW 102

 Weight loss
 Treat using:
 PTU or methimazole
o INFECTION!!!
 Radioactive iodine
o Shrinks thyroid until can be
surgically removed
o Maintain radiation precautions
 30 minute limit in room
 Lead badge for nurse
 No pregnant women or small
children visiting
 Pee sitting down
 Flush toilet twice
 Thyroid storm
 Hyperthyroidism to the extreme
 Treat by:
o Minimizing stimulation
o Giving medications to decrease HR
and BP
o Give antithyroid medications
 Gonadotropic hormones
o FSH
o LH
 Prolactin
o Helps with milk production in breasts
o Necessary for successful lactation
 Posterior pituitary (only stores, does not make hormones)
 ADH
o Helps with retaining WATER
o Diabetes insipidus
 Deficiency of ADH
 Unable to retain water
 S/S:
 Polyuria
o Seen first in kiddos when
bedwetting!
 Polydipsia (excessive drinking)
 Treat using vasopressin or desmopressin
o SIADH
 Excessive ADH
NCLEX REVIEW 103

 Retain too much water

 S/S:
 Very diluted Na so think NEURO
 Treat by:
 Minimizing fluid intake
 Monitor I&O
 Give diuretics to remove excessive fluid
 Oxytocin
o One of few hormones to work via positive feedback
o Helps with uterine contractions during labor and breast
milk secretion!
o Can be given as a medication (Pitocin) in hospital setting to
induce labor

 GI (including medications)
o Ulcers (could be from H. pylori, NSAIDs, alcohol, tobacco)
 Gastric ulcers
 Pain before eating; eating resolves
 Weight loss
 N/V
 Possible abdominal burning
 Duodenal ulcers
 Pain 1 or 2 hours after eating
 Stress ulcers
 Can give medications to minimize acidity
 PPIs
o Pantoprazole
 Can give with antacids
 Take 30 minutes before meals
NCLEX REVIEW 104

 H-2 Receptor Antagonists

o Ranitidine
 Monitor for bleeding*
 Carafate
o Protective coating, like a band-aid, that goes over ulcer
 Metoclopramide (Reglan)
o Contracts muscles in upper intestine to speed up motility
 Misoprostol (Cytotec)
o Inhibits acid and stimulates mucus
o Used to induce pregnancy.
o Esophageal varices
 Seen with portal hypertension secondary to liver cirrhosis
 Major hemorrhaging risk!!!
 Use blakenmore tubes to compress bleeding and fluid resuscitate
o Liver cirrhosis
 S/S:
 Jaundice
 Fatigue
 Encephalopathy
 Darkened urine and pale stools
 Weight loss
 N/V
 Clotting dysfunction
 Impaired nutrient absorptio
o GERD
 Reflux condition
 Implement GERD precautions
 Lay with HOB elevated 30 degrees
 Do not lay down for 30 or so minutes after eating
 Avoid spicy or acidic foods
 Exercise
 Limit caffeine
 Stop smoking/alcohol consumption
o Biliary cirrhosis
 Anything related to the gallbladder, you would monitor for jaundice,
encephalopathy, pale stool, dark urine, and impaired fat absorption
o Pancreatitis
 NEVER GIVE OPIOIDS
 Will cause further pain from spasms
 Major symptoms
 N/V
NCLEX REVIEW 105

 Upper abdominal pain that radiates to the back*

 Give pain medications that are not opioids
 Give IV fluids
 If replacing pancreatic enzymes
 Ask about pork allergy**
 Monitor amylase and bilirubin levels
o Crohn’s Disease (inflammatory bowel disease)
 Anywhere along GI tract
 Give anti-inflammatories
 Sulfonamide sulfasalazine
 Prednisone (steroids!)
 Immunosuppressants
o Ulcerative Colitis (inflammatory bowel disease)
 Large intestine
o Constipation
 Often due to:
 Lack of exercise
 Low water intake
 Low fiber intake
 Anticholinergics
 Psychological
 Medications given
 Psyllium mucilloid
o Bulk forming agent to restore peristalsis
o Must be given with water!!
 Laxatives
o Diarrhea
 Usually body’s defense mechanism against foreign pathogens or infection
 If excessive, must replace fluids and electrolytes!
 Medications given:
 Opioids
 Loperamide
 Probiotics
 Anticholinergics
o Vomiting
 Can lead to F&E problems
 Can give:
 Phenothiazines
o Prochloperazine (Compazine)
 Antihistamines
 Anticholinergics
NCLEX REVIEW 106

 Marijuana

 Positions
o Supine
 After lumbar puncture for several hours
 Monitor for orthostatic hypotension when patient gets up from this
position
 Risk for pressure ulcers on bony prominences
 Perform frequent turning every 1 to 2 hours
 Good for after cardiac catheterization
o Prone
 Lying on stomach
 Position of choice for babies and above the knee amputees
 Tummy time!
NCLEX REVIEW 107

 For amputees, do not put pillows around stub, as could cause

contractures and prevent fitting of prosthetics
o Side lying
 Left side lying good for patient after NG tube feeding to prevent reflux of
content; also good for pregnant women experiencing late or variable
decelerations during labor (provide oxygen after this)
 Also good for when giving an enema
o Sims Position
 Common sleeping position
 Use pillows to help maintain body position
o Trendelenburg position
 Patient lying supine and tilted so that feet are higher than head
 Used to help with restoring blood flow to heart to increase BP
 Seen with shock patients
o Reverse Trendelenburg position
 Patient lying supine and tilted with head higher than feet
 Helps to prevent reflux
o Semi-Fowler’s
 Position of choice for preventing reflux or maintaining ICP levels.
o High-Fowler’s
 90* angle
 Good for full respiratory excursion or preventing reflux
o Tripod position
 Used for COPD patients to help maximize expirations
 Involves using overbed table and using arms to lean forward and support
torso
o With any position, want to consider if wanting to increase blood flow or constrict
something

 Fractures (the basics)

o With fractures, key is to stabilize patient to prevent further injury
 Especially important with pelvic fractures to prevent hemorrhaging
 Fractures cause disability
 If patient is young prior to end of puberty, then fracture to growth
plate can result in unequal growth of extremities
 With head fractures,
 Monitor for signs of increasing ICP or possible stroke
o First S/S usually decreased LOC
NCLEX REVIEW 108

 Can also have CSF leaks, which would be noted by yellow halo
sign on tissue
 Emergency response to a situation
o Ensure safety of rescuer
o Primary response:
 A-airway
 B-breathing
 C-circulation
 D-disability
 E-exposure (make sure to take into consideration the environment, remove
all clothing and jewelry)
o Secondary response:
 A-allergies
 M-medications taken
 P-past medical history/pregnancies
 L-Last meal (aspiration risk?)
 E-environment (where were they found?)
o Must ensure that patient is stabilized via primary response before CT or MRI
o Heart attack (MI) protocols
 M-morphine (vasodilator)
 O-oxygen
 N-nitrates (vasodilator)
 A-Aspirin (anti-platelet)
o ACLS (life support, including CPR, oxygen, etc.)
 With any ACLS, want to check to see if stable versus unstable
 Stable: Systolic BP >90, HR 60-100, asymptomatic
o With stable, usually use medications
 Unstable: Systolic BP <90, HR <60 or >100, symptomatic
o With unstable, usually do electrical conversions in
conjunction with medications
 Supraventricular tachycardia (heart rate elevated above 120 bpm)


 Common in young adults, often secondary to medications, caffeine

 Have patient bear down first to decrease HR
 If stable, give adenosine 6 mg IV push, flush, 12 mg IV push, flush
 Can give amiodarone 150 mg over 10 minutes
NCLEX REVIEW 109

 If unstable, cardiovert patient, then adenosine

 Sinus bradycardia (HR less than 50)


 If stable, give atropine 0.5 mg IV push every 3-5 minutes w/
ceiling of 3 mg
 If unstable, pace patient using monitor
 Blocks (impulses not originating in nodes appropriately)
 3 types of heart block


 If stable, ask patient what medications they are taking
 If unstable, pace patient using monitor
 Ventricular tachycardia (be gentle to the beating heart, do NOT
defibrillate a beating heart!)


 If stable, give amiodarone to correct dysrhythmia
 If unstable and pulse, cardiovert
 If unstable and no pulse, then begin CPR and set up monitor to
defibrillate, epinephrine doses
NCLEX REVIEW 110

 Ventricular fibrillation


 Always pulseless
 Begin CPR, give 1 mg epinephrine, CPR, defibrillate, CPR,
amiodarone, CPR, defibrillate, CPR, epinephrine.
o Keep going until pulse returns or too tired to continue
 Atrial flutter (saw tooth pattern)


 Risk for clots being thrown to brain/lungs/heart
 Give Cardizem (push 20 mg, hang 10 mg)
 Atrial fibrillation (no discernible P waves)


 Risk for clots being thrown

 Give Cardizem (push 20, hang 10)
 Asystole


 No heart beat
 CPR, defibrillation, epinephrine
 PEA
NCLEX REVIEW 111


 Electrical activity present on EKG (looks usually like sinus
rhythm) but no pulse on assessment
 ASSESS THE PATIENT, NOT THE MONITOR
 Look for potential causes of PEA and correct to treat
o Hypoxia
o Hypo/hyperkalemia
o Hypoglycemia
o Trauma
o Tamponade
o Thrombi
 For EKGs, count squares b/w P waves and QRS complexes to check for
regularity
 Strips count as 6 second intervals, so count number of QRS
complexes and times by 10 to get rate per minute

 Burns
o Risk for fluid volume depletion and shock
o Key is fluid resuscitation with Lactated Ringers
 Want to save reddened area around dead, necrotic burn zone.
 Based on BSA
NCLEX REVIEW 112


 Wt in kg x % burn x 4 mL then divide by amount of hours fluid needs to
be given over (this first number is the amount per 24 hours)
o 1st degree burns
 Superficial-like sunburns, painful
nd
o 2 degree burns
 Partial thickness
 Blisters
 Can be painful unless nerve endings destroyed
rd
o 3 degree burns
 Full thickness
 White, dead skin
 No feeling
o With a burn patient, want to remove all clothing and jewelry to prevent
compartment syndrome (may have to cut through dead tissue if loss of circulation
occurs
 Keep warm environment
 Cover head
 Do NOT put on wet dressings
 Do not put vasoline on patient
o HUGE INFECTION RISK
o Carbon monoxide poisoning/inhalation injury
 Suspect if ash in patient’s mouth, singed nose hairs, drooling, hoarseness
 INTUBATE IMMEDIATELY
 Renal failure and dialysis
o BUN levels
 8 to 20
o Creatinine
NCLEX REVIEW 113

 0.7-1.5
 Creatinine clearance equals GFR
o Acute renal failure causes
 Prerenal
 Before the kidney
 Low BP
 Intrarenal
 Medications blocking it
o Contrast
 Postrenal
 Ureter obstructions
o Acute renal failure stages
 Onset
 Minimal s/s
 Oliguric
 Decreased/absent urine output
 Metabolic acidosis
 Fluid retention
 Hyponatremia
 Hyperkalemia**
 Diuretic
 Polyuria
 Hypovolemia
 Hypokalemia
 Recovery
 GFR improves
o Hemodialysis
 Need Quinton Catheter in place or AV fistula
 No BP on fistula arm
 Infection risk!
 Hear the bruit, feel the thrill
 Risk for hypotension/circulatory collapse
o Peritoneal dialysis
 Catheter inserted into abdomen
 Sterile procedure to prevent infection
 Monitor for rigid abdomen and pain (peritonitis)
 Monitor for cloudy or bloody outflow
o CRRT
 Good for preventing hypotension complications
NCLEX REVIEW 114

 And then we go little (pediatric milestones and developmentally appropriate play)

o One month:
 Marked head lag (no head control)
NCLEX REVIEW 115

 Strong grasp reflex

 Cries to express displeasure
 Quiets when hears voice
o Two months:
 Posterior fontanel closed*
 Vocalizes, coos
 Social smile
 Visually searches for sound
o Three months:
 Grasp reflex gone
 Turns head to locate sounds
 Recognizes familiar faces
o Four months:
 Drooling (beginning of teething!)
 Give cool teething toys to minimize discomfort
 Moro, tonic neck, and rooting reflexes gone
 Rolls back to side
 Safety risk!
 Grasps for objects with both hands
 Carries objects to mouth
 Safety risk!!
 Making consonant sounds
 Laughs
 Memory beginning
o Five months:
 Teeth coming in
 No head lag when pulled to sitting position**
 Can sit up if back supported well
 Turns abdomen to back
 Palmar grasp
 Discriminates family from strangers
 More vocalization
o Six months:
 Chewing and biting begin
 Rolls back to abdomen*
 Bears almost all weight when in standing position
 Holds bottle
 Imitating sounds
 Stranger fear
 Holds arms out to be picked up
 Beginning object permanence
o Seven months:
NCLEX REVIEW 116

 Sits and leans forward on both hands

 Bears full weight on feet
 Transfers objects between hands
 Unidextrous approach
 Responds to name
 Taste preferences
 Plays peek-a-boo
 Attracts attention by coughing or snorting
o Eight months:
 Regular bowel and bladder patterns
 Stands holding onto furniture
 Pincer grasp
 Increasing verbal skills
 Responds to “no”
 Dislikes dressing/diaper changes
o Nine months:
 Creeps around
 Pulls self up to standing position and stands holding furniture
 Prefers dominant hand
 Responds to verbal commands
 Does not like having face washed
o Ten months:
 Can change from prone to sitting position
 Beginning to take a step
 Says “dad” and “mama”
 Waves bye
 Object permanence
 Plays pat-a-cake
 Looks and follows pictures in book
o Eleven months:
 Cruises around
 Neat pincer grasp
 Puts one object after another into container (sequential play)
 Rolls ball to another on request
 Shakes head for no
o Twelve months:
 6-8 teeth present
 Anterior fontanel almost closed
 Babinski reflex is gone
 Any presence of this after is sign of neurological damage
 Walks with one hand held well
 Lordosis evident
 Can turn pages in a book
NCLEX REVIEW 117

 Says 3 to 5 words
 Recognizes objects by name
 Uses security blanket or toy
o Fifteen months:
 Walks without help
 Creeps up stairs
 Falls when throws a ball or running
 Scribbles
 Can use cup but rotates spoon wrong
 Enjoys pictures
 Knows 4-6 words
 Asks for objects by pointing
 No!
 Less stranger fear
 Imitates parents performing household chores
 Kisses and hugs parents and pictures
o Eighteen months:
 Picky eater!
 Toddler diet
o Avoid choking hazard foods
 Anterior fontanel closed
 Walks up stairs with hand held
 Pulls and pushes toys*
 Seats self in chair
 Throws ball overhand without falling
 Manages spoon well
 Says 10 or more words
 Gesture-word combinations
 Temper tantrums
 Domestic mimicry
 My toy
o Twenty four months (2 years old):
 16 teeth present
 Beginning to control bowel and bladder elimination
 Goes up and down stairs alone
 Kicks ball without falling
 Fine motor movements improving
 Vocabulary of 300 words and use of 2-3 word phrases
 Gives first name
 Verbalizes need for food or toileting
 Parallel play**
 Dresses self in simple clothing
o Thirty months:
NCLEX REVIEW 118

 20 teeth present
 Daytime bowel and bladder control
 Jumps with both feet
 Good hand-finger coordination (especially with coloring)
 Puts things away after playing
 Notices gender differences
o 3 years
 Nighttime bowel and bladder control
 Rides a tricycle*
 May try to dance
 Telegraphic speech
 Asks lots of questions
 Can prepare simple meals
 Dresses self almost completely
 Pulls on shoes
 Feeds self completely
 Has fears
 Is egocentric
 Able to separate from parents easier
o 4 years:
 Skips and hops on one foot
 Catches ball reliably and throws overhead
 Can use scissors
 Can lace shoes
 Exaggerates stories
 Comprehends analogies
 Selfish and impatient
 Associative play
 Imaginary friends*
 Understands time better
 Cannot conserve matter
 4-5 word sentences
 Dos and Don’ts
 Can run errands outside the home
o 5 years:
 Jumps rope*
 Skates with good balance*
 Ties shoelaces completely
 Six to eight word sentences
 Names days of week
 Total self care
 Associative play
 Enjoys cooking, sports, shopping with parents
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o Age 5-7:
 Conservation of mass, weight, and numbers occurs
o 6 years old:
 Likes to draw, print, and color
 Describes objects in pictures
 Takes bath without supervision
 Likes table games, card games
 Increasing socialization with children of own age
o 7 years old:
 Repeats skills to master them
 Develops concept of time
 Uses table knife
 Brushes and combs hair
 Group play, more cooperative
o 8-9 years old:
 Jumps, chases, skips
 Dresses self completely
 Uses common tools
 Likes to compete in games with children of both sexes
o 10-12 years old:
 Writes brief stories
 Puberty changes begin
 Uses telephone
 Raises pets
 Cooks and cleans
 Likes family

 Vaccination schedules
NCLEX REVIEW 120

o Hepatitis B
 First dose at birth
 1-2 months
 6 months-15 months
o TDaP
 2 months
 4 months
 6 months
 15 months
 4-6 years old
 Every 10 years
o Hib
 2 months
 4 months
 12-15 months
o IPV (polio)
 2 months
 4 months
 6-15 months
 4-6 years old
o MMR
 6- 12 months
o Varicella
 12-15 months
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 Common pediatric infections

o Chicken pox
 S/S:
 Blister-like rash
 Severe itching
 Fever
 Contagious until lesions scab over
 After 1-2 days of scabbing over, good to go!
 Prevent scratching, as will cause scarring
 Airborne precautions!!**
o Measles
 S/S:
 Fever
 Malaise
 Cough
 Coryza
 Conjunctivitis
 Koplik spots in mouth*
 Maculopapular rash that goes from head to trunk to lower
extremities*
 Contagious 4 days before to 4 days after rash
 Airborne precautions!***
o Rubella (German measles)
 S/S:
 Rash that starts in face and goes to rest of body
 Low fever
 Biggest risk is with pregnant women, as teratogenic effects!
 Deafness
 Cardiac defects
 Mental retardation
o Strep throat
 S/S:
 Sore throat
 Fever
 Swollen tonsils with white patches
 Body aches/rash
 Treat with antibiotics if positive for this to prevent:
 Nephrotic syndrome
 Rheumatic fever
 Scarlet fever
 Endocarditis
NCLEX REVIEW 122

o Rotavirus
 Bacteria found in unclean food and water
 Problem in that causes severe diarrhea and subsequent dehydration
o Botulism
 Floppy baby syndrome
 Often the result of giving babies honey, as has bacteria
 Respiratory arrest from relaxed diaphragm
o Tetanus
 Bacterial infection that results in lock jaw from muscle tetany and
respiratory arrest
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 Developmental theorists
o Erikson’s psychosocial development (must complete a stage before can move on
to next)
 Trust vs. Mistrust-infant (0-12 months)
 Autonomy vs. Shame and Doubt-toddler (1-3 years)
 Initiative vs. Guilt-preschooler (3-5 years old)
 Industry vs. Inferiority-school age (6-12 years)
 Identity vs. role confusion-adolescent (12-18 years old)
 Intimacy vs. isolation-young adult (18-35 years old)
 Generativity vs. stagnation-middle aged adult (giving back or mid-life
crisis?) (35-65 years old)
 Integrity vs. despair-older adult (life review) (65 years old to death)
o Piaget’s cognitive theory
 Sensorimotor stage (0-2 years)
 Interacts with environment and differentiate self from objects; uses
senses
 Preoperational stage (2-4 years)
 Objects classified simply and must think concretely; egocentric
 Concrete operational stage (7-11 years)
 Child uses logic to understand physical experiences, can conserve
matter, area, etc.
 Formal operations (11-15 years)
 Can think abstractly to make rational judgments
NCLEX REVIEW 124

 Other important theorists/theories

o Maslow’s Hierarchy of Needs (need to address lowest needs before can go to next
level)
 Basic physiological needs (lowest needs)
 Food, water, shelter, sex
 Safety needs
 Security, safety
 Belonging needs:
 Affiliation, acceptance, love
 Esteem needs:
 Feelings of accomplishment
 Self actualization needs
 Recognizing individual potential in life
 NOTE: With NCLEX, pain is not considered to be part of physiological
needs and is thus not necessarily priority!
o ADPIE
 A-assessment
 D-diagnosis
 P-planning
 I-implementation/intervention
 E-evaluation
 NOTE: For any question, always look to see if the answer is supposed to
be related to assessing, intervening, etc.
o ABCs (already discussed, but important nonetheless!)
 A-airway
 B-breathing
 C-circulation
NCLEX REVIEW 125

Back to the Basics

 Hand hygiene and infection control
o How to wash hands:
 Wet hands
 Put soap on and rub together on all surfaces (esp. under fingernails)
 Point hands down as rinsing
 When drying hands, point hands up
 Turn off faucet with paper towel
o Washing hands for at least 15 seconds in the following circumstances:
 When visibly soiled
 Before patient care
 After patient care
 With certain contact isolation patients
 C. diff!!
o Alcohol foam can be used between most patient care activities to decrease time
spent washing hands
 Must rub together until dry
 Microbes do not grow well in dry environments
o Standard precautions
 Assume any or all body fluids are potentially contaminated
 Wear gloves!
o Wash hands before and after gloving
o Contact isolation
 Wear gown and gloves!
 Take gloves off before gown, as back of gown should be clean
 MRSA
 RSV
 Respiratory virus
 C. Diff
 Active herpes infection
o Droplet precautions
 Wear a mask (and possibly face shield)
 Face shields should be worn if any suspected spray of body fluids
o Like with irrigating open wounds
 Flu
 Meningitis
o Airborne precautions
 Wear n95 respirator mask
 Has to be fitted
 Wear this mask until get out of room
NCLEX REVIEW 126

 Chicken pox
 Tuberculosis
 Surgical asepsis
o Purpose
 Trying to minimize bacterial presence within the environment
o Key notes
 The 1 inch border around the sterile field is not sterile
 Liquids must be poured into a container from 4 to 6 inches away
 If water gets on sterile field, it is contaminated
 Open sterile packages as follows:
 Open flap away from you
 Then open flap on sides
 Lastly open flap towards body
 Keep objects above waist level
 Anything that is not in line of vision is not sterile
 Anything kept out to air too long is not sterile
 Can drop sterile objects out of sterile packages onto sterile field
 HIPAA
o Don’t copy patient documents to take home
o Only allow health care members who are part of the patient’s care access records
 Don’t give to travelling chaplains, unauthorized family members, etc.
o Log out of computer to prevent others from viewing records
o If you hear people talking about a patient, first thing you do is stop them from
talking about it!!!!
 Don’t talk about things in elevator, cafeteria, etc.
NCLEX REVIEW 127

 Delegation
o Right task (first thing to consider)
o Right person (does person have necessary job description/experience to do?)
o Right circumstances (is the patient stable?)
o Right communication/direction (give as much detail as possible)
o Right supervision (do you have to monitor the delegatee performing the task
constantly? If so, then better to just do it yourself)
o The more information given for the delegatee, the better
o NEVER DELEGATE:
 Nursing process (ADPIE)
 Unstable patients
 Education (primary)
 Admissions
 IV medications
o LPNs:
 Can do reinforcement teaching
 Can give all medications except for blood products and IV medications
 Can give NG feedings/insert NG tubes
o ACPs:
 Help with transfer/ambulation of stable patients
 Cannot give any medications
 Can take vital signs, but not first vital signs post-surgical procedures
 Can help with turning and repositioning
 NO teaching
 Note the job experience of the personnel
 Time management/prioritization
o Group activities together for patients to manage time well
o Plan and set goals at the beginning of shift and be flexible, modifying goals
throughout day
o Gather all materials before entering patient’s room
o If patient falls, call for help and stay with patient*
 Therapeutic communication
o Never go for the answer related to Why questions, accusations, etc.
o Look for questions that reflect the question back at the patient
 Reflection and restatement are always good*
o With a patient who hints at wanting to commit suicide, always address this topic
to maintain patient safety!**
NCLEX REVIEW 128

 Crutch/cane walking and wheelchairs

o Crutch walking (up with the good (leg), down with the bad (leg))
 Bear weight on crutches by gripping hand grips and flexing elbows at 30*
angle
 Getting up
 Have patient hold crutches on unaffected side
 Have patient push up to feet
 Once stable, move one crutch to affected side
 Have patient move crutches six inches to side and six inches in
front of feet
o Crutch stance!
 Four point gait
 For partial weight bearing on both legs
 Have patient move right crutch forward
 Move left foot forward to be even with left crutch
 Move left crutch forward 6 to 10 inches
 Move right foot forward to make even with right crutch
 Three point gait
 For patients who cannot bear weight on one extremity
 Have patient move both crutches forward with weight on
unaffected leg
 Move unaffected leg forward, putting weight on crutches
 Move both crutches forward again with weight on unaffected leg
 Two point gait
 For partial weight bearing on both legs, but with less support than
four point
 Move left foot and right crutch forward
 Move right foot and left crutch forward
 Swing through gait
 For patients who can bear weight on both legs
 Requires arm strength
 Move both crutches forward
 Lift both feet and swing forward
 Place feet next to crutches
 Walk behind and to side of patient when teaching how to walk with
crutches
 Sitting down
 Have patient go by bedside
 Back up until patient’s legs touch bed
 Put crutches in one hand and grab bed with other
 Lower self down
NCLEX REVIEW 129

o Cane walking
 Grasp cane on unaffected side
 Move cane to side of foot and six to 12 inches in front of foot
 Wider base of support
 Move affected leg forward so even with cane
 Have patient shift weight to affected leg and cane and move unaffected leg
forward
 Have patient move cane forward and move affected leg forward again so
even with cane
 Walk along affected side in case patient needs help*
o Nursing assist
 Make sure not hypotensive
 Place gait belt around patient
 Assist patient to standing position by standing in front of her, holding gait
belt on each side,
 Rock back and forth three times, on third pull patient up
 Move to unaffected side
o Grasp gait belt at back with one hand and patient’s nearest
hand with other hand
 If no gait belt, grasp upper arm with one hand and same sided hand
 Have patient look straight ahead when walking and don’t shuffle
 If patient feels weak or tired, put in bed or chair immediately
o Walker
 Push up into standing position
 Place hands on hand grips of walker one at a time
 Push walker forward and affected leg forward four to six inches
 Have shift weight to arms and to affected leg
 Move unaffected leg forward so even with affected leg
 Walk behind her and to side in case needs assistance!
NCLEX REVIEW 130

 Transferring patient
o Bed to gurney
 Lower head of bed
 Place sheet over patient (privacy!)
 Raise bed so slightly higher than gurney
 Have two nurses on side where patient will roll and one patient on other
side
 Have patient cross arms over chest
 Roll both sides of drawsheet in and grasp
 Roll patient onto side
 Transfer board under
 Put on bed
 Make sure breaks on bed and gurney…
 Pull patient onto gurney and center and assist to comfortable position.
Make sure all side rails up
o Lying, sitting, standing
 Put bed at 30* angle
 Put blankets away
 Assist patient into side lying position
 Ask patient to bend knees
 Put self at level of patient’s hips
 Put one hand around patient’s neck and other around legs to assist with
turning patient to get legs over edge of bed
 Sitting position!
 Keep standing in front of him until know stable.
 Help patient put on shoes
 Gait belt
o Mechanical lift
 Ensure wheel chair is near bed.
 Side lying position away from nurse
 Sling should go under patient from shoulders to knees
 Raise up side rail and go to other side of bed
 Side lying position away from nurse so sling completely under patient and
flat
 Get patient supine again
 Put lift mechanism directly above patient
 Have patient cross arms over chest
 Raise HOB
 Have straps all attached
 Lift patient and slide off bed until over wheelchair