Mark Klimek's Lecture Guide Overview

Mark Klimek's lectures are organized into 12 comprehensive sessions covering the most critical topics for the NCLEX exam. Each lecture focuses on high-yield content that frequently appears on the test.

The lectures cover:

• Acid-Base Balance & Ventilators (Lecture 1)
• Alcohol, Aminoglycosides, and Drug Assessments $Lecture 2-3$
• Psychiatric Nursing and Mobility Assistance (Lecture 4)
• Diabetes Management and Endocrine Disorders $Lecture 5-7$
• Laboratory Values and Interpretation (Lecture 8)
• Psychiatric Medications (Lecture 9)
• Maternity and Neonatal Care $Lecture 10-11$
• Prioritization and Test-Taking Strategies (Lecture 12)

Study Tip: Focus on understanding the principles behind each topic rather than memorizing facts. Mark Klimek's approach emphasizes critical thinking skills that help you apply nursing knowledge to any question format.

This guide compiles essential points from all lectures to help you efficiently review key concepts and prepare for success on your NCLEX examination.

Acid-Base Balance and Ventilators

Understanding acid-base balance is crucial for interpreting lab values and determining appropriate interventions. The key values to remember are:

• Normal pH: 7.35 to 7.45
• Normal CO2: 35 to 45
• Normal HCO3: 22 to 26

To determine acid-base imbalances, follow these steps:

1. Check the pH first - below 7.35 indicates acidosis, above 7.45 indicates alkalosis
2. Use the "Rule of the Bs" - if pH and Bicarbonate move in the same direction, the imbalance is metabolic; if opposite, it's respiratory

Remember that as pH changes, so do other physiological responses:

• Alkalosis (pH > 7.45): everything goes up - tachycardia, tachypnea, hypertension, seizures, irritability (except potassium, which goes down)
• Acidosis (pH < 7.35): everything goes down - bradycardia, bradypnea, hypotension, lethargy (except potassium, which goes up)

Ventilator Management:

• High pressure alarms indicate increased resistance to airflow (kinks in tubing, condensation, mucus plugs)
• Low pressure alarms indicate decreased resistance (disconnected tubing)

Clinical Pearl: "MAC Kussmaul" is the only acid-base imbalance to cause both Metabolic ACidosis and Kussmaul respirations (deep, rapid breathing).

When weaning a patient off a ventilator, ensure respiratory acidosis isn't present, as this indicates the patient isn't ready to breathe independently.

Alcohol and Drug Management

Alcoholism presents unique nursing challenges, with denial being the #1 psychological problem. Your approach should differ based on whether you're dealing with:

• Denial in loss/grief - Support the patient (DABDA stages: Denial, Anger, Bargaining, Depression, Acceptance)
• Denial in abuse - Confront the patient by pointing out discrepancies between words and actions

Key Addiction Concepts:

• Dependency: The abuser gets others to make decisions for them
• Co-dependency: The enabler derives self-esteem from helping the abuser
• Manipulation: The abuser gets others to do harmful things

Wernicke-Korsakoff Syndrome:

• Caused by vitamin B1 (thiamine) deficiency
• Primary symptoms: amnesia and confabulation (making up stories)
• When a patient confabulates, redirect them to something they can do
• The condition is: preventable, arrestable, but often irreversible (70%)

Antabuse (Disulfiram):

• Takes 2 weeks to become effective and lasts 2 weeks
• Patients must avoid all forms of alcohol, including mouthwash, cologne, elixirs, and many OTC liquid medicines

Important: When assessing drug overdose, first determine if it's an Upper or Downer. "Uppers" cause elevated vital signs and symptoms, while "Downers" cause depression of vital signs and symptoms.

For newborns of substance-abusing mothers: assume intoxication in the first 24 hours after birth, and withdrawal after 24 hours.

Aminoglycosides and Drug Levels

Aminoglycosides are powerful antibiotics used when other options fail. They're among the top 5 most tested drugs on NCLEX, but require careful monitoring due to their narrow therapeutic index.

Key Aminoglycosides:

• Gentamycin
• Vancomycin
• Clindamycin
• Streptomycin
• Tobramycin

Not in this family are drugs with "THRO" in the middle (Azithromycin, Clarithromycin, Erythromycin).

Major Side Effects:

• Ototoxicity (ear poisoning): Monitor hearing, balance, tinnitus
• Nephrotoxicity (kidney damage): Monitor creatinine levels

Administration Details:

• Give IM or IV (not PO, as they're not absorbed)
• Exceptions for oral administration: hepatic encephalopathy, pre-op bowel surgery (to sterilize the bowel)
• Monitor drug levels through troughs and peaks $"TAP" - Trough, Administer, Peak$

When to Draw Levels:

• Trough: 30 minutes before next dose
• Peak: Depends on route
  • IV: 15-30 minutes after infusion completes
  • IM: 30-60 minutes after injection
  • SL: 5-10 minutes after dissolution

Clinical Tip: Remember "Mean Old Mycin" for aminoglycosides. They treat "mean old infections" like TB, septic peritonitis, and severe wound infections. The therapeutic window is narrow, so careful monitoring is essential.

When asking about peak timing, always go with the latest time that doesn't exceed the window.

Cardiac Medications and Chest Tubes

Calcium Channel Blockers (CCBs):

• Act as "Valium for the heart" - they calm and slow cardiac activity
• Have negative inotropic, chronotropic, and dromotropic effects
• Used to treat "A, AA, AAA": Antihypertensive, AntiAnginal, AntiAtrialArrhythmia
• Most end in "-dipine"
• Monitor BP and hold if SBP < 100

Cardiac Arrhythmias: The six most tested rhythms on NCLEX:

1. Asystole - flat line (no QRS)
2. Atrial flutter - sawtooth P waves
3. Atrial fibrillation - chaotic P waves
4. Ventricular fibrillation - chaotic QRS
5. Ventricular tachycardia - bizarre QRS
6. PVCs - periodic wide, bizarre QRS

Treatment Approaches:

• Ventricular arrhythmias $V-tach, PVCs$: Treat with Lidocaine or Amiodarone
• Supraventricular arrhythmias: Use "ABCDs" - Adenosine, Beta-blockers, CCBs, Digitalis
• V-fib: Defibrillation
• Asystole: Epinephrine and Atropine

Chest Tube Management:

• Purpose: Reestablish negative pressure in pleural space
• Pneumothorax: Tube removes air (apical placement)
• Hemothorax: Tube removes blood (basilar placement)

Critical Nursing Action: If a chest tube water seal breaks, immediately: 1) Clamp the tube, 2) Cut the tube, 3) Submerge end in sterile water, 4) Unclamp. This sequence must be completed in under 15 seconds.

Watch for bubbling patterns - continuous bubbling in the water seal chamber indicates a leak, while intermittent bubbling is normal. Conversely, continuous bubbling in the suction control chamber is expected.

Congenital Heart Defects and Infection Control

Congenital Heart Defects: Memorize "TRouBLe" defects - these are serious conditions requiring immediate intervention:

• Tetralogy of Fallot (PROVE: Pulmonary stenosis, Right ventricular hypertrophy, Overriding aorta, VSD)
• Truncus arteriosus
• Transposition of great vessels
• Tricuspid atresia
• Totally anomalous pulmonary venous return
• Left ventricular hypoplastic syndrome

Patients with these defects:

• Need surgery soon to survive
• Have delayed growth and development
• Have shortened life expectancy
• May need home cardiac monitoring

"No TRouBLe" defects (less severe):

• Ventricular septal defect (VSD)
• Patent ductus arteriosus (PDA)
• Patent foramen ovale
• Atrial septal defect
• Pulmonic stenosis

Transmission-Based Precautions:

1. Contact Precautions:

   • For enteric conditions, staph, RSV, herpes
   • PPE: Handwashing → Gown → Gloves

2. Droplet Precautions:

   • For pathogens traveling < 3 feet through coughing/sneezing
   • Examples: Meningitis, H. influenzae
   • PPE: Handwashing → Mask → Goggle/Face shield → Gloves

3. Airborne Precautions ("Air MTV"):

   • For MMR, TB, Varicella
   • Requires negative airflow room
   • PPE: Handwashing → Goggle/Face shield → Gloves
   • Wear mask when leaving room

Remember: Put PPE on with "Gs" in reverse alphabetical order (Gown, Mask, Goggle, Gloves) and remove in alphabetical order (Gloves, Goggle, Gown, Mask).

All children with congenital heart defects have murmurs, but an echocardiogram is needed to identify the specific defect.

Mobility Aids and Psychiatric Assessment

Crutch Measurement:

• 2-3 finger widths between crutch pad and axilla
• Elbow flexed at 30 degrees
• Tip 6 inches in front and to side of foot

Crutch Gaits:

• 2-point: For mild bilateral weakness (opposite crutch and leg move together)
• 3-point: For one affected leg (both crutches and affected leg, then unaffected leg)
• 4-point: For severe bilateral weakness (slowest but most stable)
• Swing-through: For non-weight bearing (amputees)

Remember: "Up with the Good, Down with the Bad" for stairs.

Cane & Walker Use:

• Hold cane on unaffected side
• For walkers: "Pick it up, Set it down, Walk to it"

Psychiatric Assessment: The first question to ask: Is the patient psychotic or non-psychotic?

Non-psychotic patients:

• Have insight and reality-based thinking
• Respond well to therapeutic communication
• Use reflection, clarification, amplification, restatement

Psychotic patients:

• Lack insight, not reality-based
• May have delusions, hallucinations, or illusions
• Delusions: False, fixed beliefs with no sensory component
• Hallucinations: Sensory experiences without external stimuli
• Illusions: Misinterpretation of actual stimuli

Clinical Approach: For functional psychosis, use the 4-step process: (1) Acknowledge feelings, (2) Present reality, (3) Set limits, (4) Enforce limits. For dementia, acknowledge feelings and redirect. For delirium, acknowledge feelings and provide reassurance.

The approach differs based on the type of psychosis: functional (chemical imbalance), dementia (brain damage), or delirium (temporary due to medical issues).

Diabetes and Metabolic Disorders

Types of Diabetes:

• Diabetes Mellitus (DM): Error in glucose metabolism
  • Type 1: Insulin dependent, ketosis-prone
  • Type 2: Non-insulin dependent, non-ketosis prone
• Diabetes Insipidus (DI): Low ADH causing polyuria and polydipsia
• SIADH: Opposite of DI - excessive ADH causing fluid retention

Treatment Approaches:

• DM Type 1: "DIE" - Diet, Insulin (most important), Exercise
• DM Type 2: "DOA" - Diet (most important), Oral hypoglycemics, Activity

Insulin Types:

1. Regular (R): Clear solution, IV drip

   • Pattern: 1-2-4 $onset-peak-duration in hours$

2. NPH (N): Cloudy, intermediate

   • Pattern: 6-8/10-12 $onset-peak-duration in hours$

3. Lispro (Humalog): Given with meals

   • Pattern: 15min-30min-3hrs $onset-peak-duration$

4. Glargine (Lantus): Long-acting, no peak

   • Duration: 12-24 hours

Acute Complications:

• Hypoglycemia: Too much insulin, not enough food, excess exercise

  • S/Sx: "Drunk" presentation plus shock symptoms
  • Treatment: Rapidly metabolizable carbohydrates

• DKA (Type 1): Dehydration, Ketones, Acidosis

  • Treatment: Insulin IV, fluid replacement

• HHNK/HHS (Type 2): Severe dehydration, no ketones

  • Treatment: Fluid replacement (primary)

Remember: Exercise potentiates insulin action. During illness, patients need insulin even when not eating due to rising glucose levels. The Hb A1C test is the best indicator of long-term glucose control (normal <6, poor control >8).

When monitoring for hypoglycemia after insulin administration, check at the peak time of the specific insulin type.

Drug Toxicities and Gastrointestinal Disorders

Five Critical Medications to Monitor:

1. Lithium (for bipolar disorder)

   • Therapeutic level: 0.6-1.2
   • Toxic level: >2.0

2. Lanoxin/Digoxin (for atrial fibrillation, CHF)

   • Therapeutic level: 1-2
   • Toxic level: >2

3. Aminophylline (bronchodilator)

   • Therapeutic level: 10-20
   • Toxic level: >20

4. Dilantin/Phenytoin (seizure medication)

   • Therapeutic level: 10-20
   • Toxic level: >20

5. Bilirubin (in newborns)

   • Normal in adults: 0.2-1.2
   • Elevated in newborns: 10-20
   • Toxic level (kernicterus): >20

Pattern to remember:

• 1s and 10s
• 2s and 20s $Lithium and Lanoxin = 2; Aminophylline, Dilantin, Bilirubin = 20$

Gastrointestinal Disorders:

Hiatal Hernia:

• Gastric acid refluxes upward
• Treatment: Elevate head of bed, increase fluids with meals, increase carb content

Dumping Syndrome:

• Gastric contents empty too quickly into duodenum
• Symptoms: "Drunk + Shock + Acute abdominal distress"
• Treatment: Lower head of bed, decrease fluids before/after meals, decrease carbs

Clinical Tip: Hiatal hernia = everything HIGH (elevate, increase). Dumping syndrome = everything LOW (lower, decrease).

Adding protein to the diet has opposite effects of carbohydrates - it slows digestion. So give low protein for hiatal hernia and high protein for dumping syndrome.

Electrolyte Imbalances

Understanding electrolyte imbalances requires memorizing these key rules:

1. Potassium (Kalemia): Symptoms move in the same direction as the prefix, except HR and urine output go opposite.

   Hyperkalemia:

   • Brain: seizures, agitation, irritability
   • Heart: tented T waves, elevated ST, bradycardia
   • Bowel: diarrhea, increased sounds
   • Muscle: spasticity, hyperreflexia
   • Urine output: decreased

   Hypokalemia:

   • Brain: lethargy
   • Heart: U waves, tachycardia
   • Bowel: constipation, ileus
   • Muscle: flaccidity, hyporeflexia
   • Urine output: increased

2. Calcium (Calcemia): Symptoms move in the opposite direction of the prefix.

   Hypercalcemia: everything goes down - bradycardia, bradypnea, flaccidity, lethargy

   Hypocalcemia: everything goes up - agitation, tachycardia, spasm, seizures, Chvostek's sign, Trousseau's sign

3. Magnesium (Magnesemia): Symptoms also move opposite to the prefix.

4. Sodium (Natremia):

   • Hypernatremia = Dehydration
   • Hyponatremia = Fluid overload

Remember: The earliest sign of any electrolyte imbalance is paresthesia (numbness and tingling), especially around the mouth.

Emergency Treatment for Hyperkalemia:

1. D5W and regular insulin $fast-acting$
2. Kayexalate $longer-term solution$
3. For best results, give both simultaneously

Never push potassium IV! Always dilute to <40 mEq/L of fluid.