NCLEX Success: Test Day Advice Busters!

Ok so lets talk a little bit about that dreaded day. Most people are really nervous, they have itchy pants or just feel nauseous. Well that’s to be expected. When the day finally arrives you better be ready for it, although guaranteed you won’t feel ready! So now I’m going to tackle some of those test day cliches!

Things you’ve probably been told to do:

• Get a good nights sleep – well that is easier said than done. The likelihood is that you will toss and turn all night. The alternative is to take some melatonin or NyQuil the night before and have a family member or a friend AND an alarm clock set to wake you up. It’s true that a good nights sleep will help you, but don’t beat yourself up if you struggle to get some zzzz’s the night before.
• Eat a healthy meal the night before and a good breakfast the day of – This is dependent on what kind of eater you are. Do you binge eat under stress? Or do you lose your appetite? The fact is your mind is focused on the test, just eat whatever you want! One healthy meal isn’t going to help  you the night before. The day of, it is important to have something in your stomach, but if you are too nauseous then just stick to water.
• Don’t study the day of the test – Yeah, I was told that too; what a load of crap! My exam was at 2pm in the afternoon, and you’re damn right I studied before it. I didn’t go hardcore and freak out over the things I didn’t know. I simply went over the rationales of the mock test I took the day before. I felt like it got me in the groove without freaking me out. At the end of the day there will be questions that you just don’t know, but NCLEX know that, which is why they keep evaluating you with each question and will shut off when you have proved yourself.
• Aim to pass in 75 questions – This is a stupid notion; you should not expect or hope to be done in 75Q. Mentally prepare yourself to go the whole way. If you get to question 75 and it doesn’t shut off it doesn’t mean you failed – it means you still have to prove yourself, so take the challenge!!! Don’t freak out when questions 76 pops up, I had a friend that passed and it shut off after Q76. It is important to just take each question at a time, if you are clueless, then go with your gut and just pick one, you have to keep pace.
• You can always take it again – This isn’t a bad thing to keep in mind. We put a lot of pressure on ourselves; we don’t want to be the ones who fail, BUT, life is full of set backs and the fact that you can take it again if necessary should relieve some of that pressure. If you fail it doesn’t make you stupid, there are so many factors involved in taking the test, you just have to draw up a new study plan and start over.

You can do it, NCLEX isn’t a monster, just a bridge to cross! Best of luck to you!

Cardiac Tamponade

This has nothing to do with tampons in the heart ok! Just an FYI.

When blood or fluid accumulate in the sac which surrounds the heart it exerts pressure against the heart, making it harder for the heart to pump. As you can imagine, if the ventricles cannot fill fully or contract effectively then cardiac output decreases. Decrease cardiac output is not good news!

So how do you know if someone has this?

Well the symptoms are nothing unusual: chest pain, restlessness, quick shallow breathing, palpitations, pallor, tachycardia, weak peripheral pulses, pulsus paradoxical, distended neck veins, low BP… (do these all sound a little familiar? MI anyone?) Well causes of cardiac tamponade can be MI, Dissecting aortic aneurysm (thoracic), end-stage lung cancer, heart surgery, Pericarditis caused by bacterial or viral infections, or direct wounds to the heart.

How do we diagnose? Echocardiogram is the usual diagnostic tool, but MRI, CT, CXR or EKG can also highlight or confirm this.

Can you see the halo of fluid around the heart?

This is an emergency! The fluid must be drained to reduce damage to the myocardium and reestablish cardiac output.

Pericardiocentesis is a procedure that uses a needle to remove fluid from the pericardial sac, the tissue that surrounds the heart. The patient will be hyperoxygenated, given fluids to maintain blood pressure. It is important to note that a pericardiocentesis may have to be repeated because cardiac tamponade can return. With fast treatment the outcome is usual good, without treatment death is immanent.

A pericardial draining tube may be placed during surgery to keep in place postop. The drainage will be measured every shift and documentation on the color, amount and consistency is very important! The tube will usually be removed slowly over the postop recovery weeks at the discretion of the cardiologist.

NCLEX Success: Remember your A-B-Cs!

Say it with me: AIRWAY, BREATHING, CIRCULATION!

If you have renewed CPR with AHA recently you’ll know that they have changed that to CAB from ABC, but for NCLEX you need to stick with the ABC.

So here comes that irritating priority question. You try to apply Maslow but all options are physiological, so there is nothing to eliminate. What do you do? You apply the ABCs.

Airway will always be the most important factor to take priority: anaphylaxis? Choking? So look for it, if it isn’t there, look for breathing, it could be simple like raising HOB to decrease dyspnea in a CHF pt – keep focused on the “B” until you can rule it out. If no luck at that point, move to circulation. Hemmorhage? Potential for bleed? Change in vitals (↑HR, ↓BP)?

Look at the big picture and apply all the ABCs and use them to lead you to the right answer! Priorities will always contain ABC/Maslow or combination! Use your question answering skills! 🙂

NCLEX Success: Maslow’s Hierarchy of Needs

Maslow is a great tool to narrowing down or answering NCLEX questions. Those pesky priority questions are the ones in which Maslow can lend a helping hand. Here is how you use the Maslow Strategy:

1. Look at the answer choices. Determine if the answer choices are both physiological and psychosocial, if they are – apply the Maslow strategy.
2. Now, eliminate all psychosocial answer choices.
3.  If the answer choice is physiological, don’t eliminate it. Maslow states that physiological needs must be met first. Although pain certainly has a physiological component, it is considered a psychosocial need on Nclex.

Hypocalcemia – Got Milk?

These test for hypocalcemia seem so random? Who in the world discovered them? Well, I guess that’s not the most important point here, the fact is: hypocalcemia is very dangerous! Think about the role calcium plays in our muscles and bones? Our heart is a muscle, so you will expect to see changes there if calcium is either low or high. So these signs Chvostek and Trousseau – I guess they are the geniuses who discovered the sx, but seriously? Could they get more complex names?! Ugh! Ok so how I remember the two, is Chvostek is “Cheek”, and Trousseau’s is “Thumb”. I find that this helps me to differentiate between the two.

Major sx to watch for is TETANY – what in the world is that you might be thinking. Well is basically means muscle spasms or twitching. So why does calcium affect muscles in this way? Calcium blocks sodium channels and stops depolarization (contraction) of nerve and muscle fibers, therefore, a lack of calcium reduces the threshold for depolarization, making the muscles jerky.

A mnemonic for hypocalceima sx:

“CATS go numb”- Convulsions, Arrhythmias, Tetany and numbness/parasthesias in hands, feet, around mouth and lips.

So is this just someone who is skipping their milk and cookies at night? No. Hypocalcemia is something seen with an array of diseases. Calcium is found in the bones, joined with other substances or free floating in the blood. Sure people with eating disorders or severe malnutirtion can have this, but it is mostly seen with those with thyroid issues. Parathyroid hormone (PTH) in a healthy person is what tightly controls calcium levels in the body. So how can PTH stop working? Well if I were assessing my patient for hypocalcemia, a crucial question would be any surgery or injury to their neck or head. Why is this? Well damage to the parathyroid in any way can inhibit the function of PTH and hypocalemia ensues. Hypoparathyroidism would be the name for this abnormality in PTH function. Surgical destruction of the parathyroid glands by parathyroidectomy, partial or total thyroidectomy, or neck dissection for head and neck cancers or any autoimmune issue can be a good indicator of why hypocalcemia is presenting.

Great Little Story to Remember Those AV Heart Blocks!

❤The Sad Story of a Struggling Marriage…❤

1st Degree AVB
Husband comes home late every night at the same time, but he
ALWAYS comes home!!!

** P waves aren’t on time but always present! Prolonged PRI

2nd Degree AVB Type 1 (Mobitz 1 or Wenckebach)
Husband comes home later and later and later until one night he
doesn’t come home at all, then the pattern starts all over again!!!

**P wave “Going, going, gone”, PRI gets longer & longer till P is dropped

2nd Degree AVB Type 2 (Mobitz 2)
Husband comes at the same time every night, but there are some
nights that he just doesn’t come home!!!

**P wave is on time but randomly drops

3rd Degree AVB (Complete)
Husband and wife are finally divorced but can’t afford to move out of
their house because of the bad economy. As a result, they are still
living under the same roof, but leading two separate lives!!! It
appears as if they’re still married, but they’re not! There is no
communication between them!!!

** P waves, PRI are not in sync with Ventricular activity (QRS) and its a hot mess!

NCLEX Success

For all those who are embarking on their NCLEX – I feel for you!
I remember the relentless studying, the anxiety, and the need to use the bathroom every 2 minutes while in the waiting room before taking me test! Arghhhh! It was a momentous day in the life of a student. Overnight you become an RN, like a caterpillar to a butterfly…. Ok I’ll cut the crappy metaphors, we all know the torture! But do not despair, I hope to have helpful tip posts just for you NCLEXers.

This first tip is from my personal experience. Often times on the forum I saw people asking “what books did you use?”
So here is my list:

– Kaplan Strategies, Practice and Review
– Fluids & Electrolytes Made Incredibly Easy
– Prioritization, Delegation, and Assignment: Practice Exercisers for the NCLEX Exam – LaCharity

More Tips to Come! Good Luck!

EKG Time!

EKG TIME! (For basic understanding)

Ok so for many the EKG is a weird and wonderful map of squiggles, but actually each little squiggle is very important in translating the conduction of the heart. From your A&P course you should know that the normal conduction of the heart starts in the SA node in the Right Atrium, it travels to the AV node in the wall of the right atrium (middle of the heart), then through the Bundle of His/Left & Right Bundle Branches and down through the Purkinje fibers. The EKG is basically a map of that scenario. Imagine that you are in a car in San Antonio (SA node), you need to drive to Aventura (AV node), then you go through the spaghetti junction (Bundle of His) while heading to Pittsburg (Purkinje fibers) – if you were to use Google maps, you would have the route highlighted out on the roads you have to take, right? Well that is basically what an EKG is! It is the highlighted route the conduction took through the heart.

I hope that has given you a little clarity on those squiggly lines, haha!

Now what does the map tell us?

As you can see we use letters to signify different areas of the squiggle. You can see that P is a little bump at the beginning. This is showing us that the atria of the heart are depolarizing (another fancy word for compress or pump). The atria is pushing the blood into the ventricles. P shows that the car has left the SA node in the Right Atrium and is traveling to the AV node in the middle of the heart. From P to Q (called PR complex),  the car then leaves the AV node and travels down through the Bundle of His. One the car travels out from the Bundle of His down the Bundle Branches, through the Purkinje fibers and the rest of the heart so a QRS complex occurs. The QRS shows that the ventricles have received all the blood from the atria and pumps it back out to lungs (right V) and aorta (left V). And with that you have just witnessed a heartbeat.

Well what about the leftover squiggles…

So between the S and the T (called the ST segment), we see the heart recovering from the heartbeat, otherwise known as Ventricular REpolarization. Think about clenching your fist really hard and then relaxing, that is in essence what the heart is doing. The ST segment is very important to monitor on an EKG strip because if you are looking for something pathological, such as an MI, you might just find it here with ST segment elevation. This would mean the patient would be diagnosed as having a STEMI. We could continue this further, but we’ll save the pathological changes for another time.

So following the T wave, the heart is now ready to complete another beat! We have come full circle!

I hope you found this helpful, it is purely for basic understanding, EKG’s can be much more in depth! My best advice is so search YouTube for videos, as visualizing this is the best way to learn what it going on inside the heart!

Good Resources:

http://www.youtube.com/watch?v=7b98JcGIGyE

http://handwrittentutorials.com/

Rapid Interpretation of EKG’s 6th Ed. – Dale Durbin (really good book)