NCLEX-RN Physiological Adaptation Summary

A glucose below 70 mg/dL is hypoglycemia (low blood sugar). For a client who is awake and can swallow, the first step is the "15-15 rule":

1. Give about 15 grams of fast-acting carbohydrate (for example, 4 ounces of juice or regular soda, or glucose tablets).
2. Recheck the glucose in 15 minutes.
3. Repeat if it is still low. Once it is normal, give a snack or meal if the next meal is not soon.

Wrong choices

• "50% dextrose IV": used when the client cannot swallow safely or is unconscious and has IV access.
• "Glucagon injection": used when the client cannot swallow and there is no IV access.
• "Recheck in 1 hour": waiting without treatment lets the sugar drop further and can lead to seizures or loss of consciousness.

Sudden one-sided weakness and facial droop are signs of a stroke. For an ischemic stroke (caused by a clot), clot-dissolving medicine and clot-removal procedures can only be used within certain time windows. Treatment decisions start from the time the client was last known to be normal ("last known well"). If the client woke up with symptoms, the last known well time is when they went to sleep.

The nurse also checks the blood glucose quickly, since low blood sugar can look like a stroke.

Wrong choices

• "Usual diet": useful later, but it does not guide emergency treatment.
• "Family history of stroke": a risk factor, but it does not change what is done right now.
• "Last flu vaccine": not related to emergency stroke care.

Think of where the blood backs up.

• The left side of the heart receives blood from the lungs. When it fails, blood backs up into the lungs: crackles, shortness of breath, cough, and trouble breathing when lying flat.
• The right side receives blood from the body. When it fails, blood backs up into the body: ankle swelling, enlarged liver, fluid in the abdomen, and swollen neck veins.

Many clients have both, but crackles are the sign most directly linked to the left side.

Wrong choices

• "Swelling of the ankles": a sign of right-sided failure.
• "Enlarged liver": a sign of right-sided failure.
• "Ascites": a sign of right-sided failure.

Read the blood gas in steps.

1. pH 7.30 is low → acidosis.
2. PaCO₂ 55 is high. CO₂ acts like an acid, and high CO₂ matches the low pH → the cause is respiratory.
3. HCO₃⁻ 25 is normal → the kidneys have not yet compensated.

Result: respiratory acidosis (uncompensated). This fits the story: opioids slow breathing, so CO₂ builds up in the blood.

Wrong choices

• "Respiratory alkalosis": would have a high pH and low CO₂, as with fast breathing.
• "Metabolic acidosis": would have a low pH with a low bicarbonate.
• "Metabolic alkalosis": would have a high pH with a high bicarbonate.

Insulin moves glucose and potassium from the blood into the cells. In DKA, the blood potassium may look normal or even high at first, but the body's total potassium is often low. Once IV insulin starts, potassium moves into the cells quickly and the blood level can drop fast. Low potassium can cause dangerous heart rhythms.

So potassium is checked often (as ordered), the client is usually on a heart monitor, and potassium is added to the IV fluids when needed. Blood glucose is also checked often.

Wrong choices

• "Serum calcium": not the key electrolyte affected by insulin therapy.
• "Hemoglobin": not directly changed by insulin.
• "Serum albumin": a nutrition and liver marker that changes slowly; not the focus during DKA treatment.

The strip shows ventricular fibrillation (VF): fast, chaotic waves of different sizes with no P waves and no QRS complexes. The heart is only quivering, so it pumps no blood. That is why the client has no pulse.

VF is a shockable rhythm (VF and pulseless ventricular tachycardia are the two shockable rhythms in adult cardiac arrest). The most important treatment is an unsynchronized shock (defibrillation) as soon as the defibrillator is ready. Keep doing high-quality CPR until the moment of the shock, then restart CPR right away for 2 minutes before the next rhythm check. Every minute without a shock lowers the chance of survival.

Wrong choices

• *Synchronized cardioversion*: the machine waits for a QRS complex to time the shock. VF has no QRS, so the shock may never fire. Cardioversion is for unstable rhythms that still have a pulse.
• *Amiodarone before any shock*: amiodarone is given only for VF that continues after shocks (shock-refractory VF). It never replaces or delays the first shock.
• *Atropine*: atropine treats a slow heart rate (bradycardia) with a pulse. It has no role in VF.

The strip shows atrial fibrillation (AFib):

1. The QRS complexes are narrow, but the space between them changes with no pattern ("irregularly irregular").
2. There are no P waves. Instead the baseline between beats is wavy (fibrillatory waves), because the upper chambers (atria) only quiver.

When the atria quiver, blood pools and can form a clot. The clot can travel to the brain and cause a stroke. That is why many clients with AFib take an anticoagulant (blood thinner). This client is stable (alert, normal BP), so the priority is teaching: take the anticoagulant exactly as prescribed, do not skip doses, report bleeding (black stools, blood in urine, easy bruising), and know the warning signs of stroke.

Wrong choices

• *Ventricular tachycardia*: VT has wide, fast, regular QRS complexes. This strip has narrow QRS complexes, and the client is alert with a pulse, so defibrillation is not indicated.
• *Sinus arrhythmia*: sinus arrhythmia has a normal P wave before every QRS. This strip has no P waves.
• *Atrial flutter*: flutter shows regular "saw-tooth" waves and usually a regular rate. Also, caffeine reduction is not the main treatment.

Potassium affects the electrical activity of the heart. When potassium is high (hyperkalemia), an early and well-known ECG sign is tall, narrow, peaked T waves. As the level rises higher, the P waves flatten, the QRS widens, and dangerous rhythms or cardiac arrest can occur.

When potassium is low (hypokalemia), the T waves flatten and U waves may appear.

Wrong choices

• "Prominent U waves": a sign of low potassium, the opposite problem.
• "Sawtooth flutter waves": describes atrial flutter, not a potassium change.
• "Irregular rhythm with no P waves": describes atrial fibrillation, not the classic sign of high potassium.

The rule of nines quickly estimates how much skin is burned in an adult. The body is divided into areas worth about 9% or multiples of 9%:

• Head and neck: 9%
• Each arm: 9%
• Front of the trunk: 18%; back of the trunk: 18%
• Each leg (front and back): 18%
• Groin area: 1%

Both whole legs: 18% + 18% = 36%.

Wrong choices

• "18%": this is only one whole leg, or the front of both legs.
• "27%": does not match any combination of whole legs.
• "45%": too high; this would include more than both legs.

Calcium helps keep nerves and muscles calm. When calcium is low, nerves become over-excited. Signs include tingling around the mouth and fingers, muscle cramps, and spasms. Two classic tests:

• Chvostek sign: tapping the cheek in front of the ear makes the face twitch.
• Trousseau sign: inflating a blood pressure cuff on the arm causes a hand spasm.

Wrong choices

• "Muscle weakness with decreased reflexes": fits high calcium, when nerves are slowed down.
• "Constipation with high thirst": also fits high calcium.
• "Slow reflexes and drowsiness": fits high calcium or high magnesium, not low calcium.