01 Acid Base Principles

I'm Mark Clement and I'll be doing a review and Linda Caves is out at the table. She has a lot, she can answer any questions about logistics, about the course. So she's best asked on that. Usually if you have a question on just for her, you can just go to her first. She'll be here today and probably tomorrow and probably Sunday, but I'm not exactly certain on Sunday. She may or may not be there. You should have in your possession a blue and yellow book. If you don't and you didn't register, you need to go out and register now. If that's done, I'd like to thank Shannon and Derek for all their work getting organized. It's a lot of work. And amazingly, he's just like two weeks. I know I know professional event planners that can't pull off anything, but they have six months. You guys are not going to event planning. The lights, we don't know anything about the lights, are they? No, I try to get them back on there. We have some functioning with the lights. Are they even trying or did they just say? So they're not going to try to fix that. So we're going to be, yeah, now is that sunlight? Or is that ambient light? That's true. We're going to say if that's sunlight, when it goes down, it's going to be a little dark. Hopefully it's just backlighting. You think that's what it is? Yeah. Okay, good. Well, that'll give us some lighting. My eyes actually are, when I first came in there, they seemed pretty dark and you would actually start to like a lot of lighter. I guess I'm accommodating. So you'll have to take notes in this light. I apologize for that, but that's just the way things happen sometimes. I think there's a little more light over here if you're having a hard time. That might be a good place to sit. Can you see me? Yeah, can you hear me? Of course, if you didn't, you wouldn't answer any of this. So I guess that's just the question as if you hear me or not. But I don't usually use microphones because I don't usually need a microphone, but it becomes a problem with you having to really attend to hear me. Let me know, and I can use a microphone, but I don't like to use it, and I don't usually have to, and I've lectured in auditories this size and bigger without microphones, and my voice usually lasts. So it should work. Logistics there are men and women's restaurants right out to the left for those of you who are from the caramel. Well, no, anybody can use the breath. I'm telling those of you that aren't from the caramel, where the rest of the food are or separate restrooms from our caramel people. Well, I feel like what I say, people take me literally. Also, there are chips and salsa out there, I guess, and then tomorrow, Chen is arranged for pizza to be brought in for lunch time. And so you can plan on that. And if you wanted to bring some extra little things to throw on the table, that'd be fine, too. Is that correct? See, Chen, anything else I needed to tell them from your information? No, we are planning on how to lift it. If anybody's great baker, and you want to raise your hand, I'm very happy with that. I'm sorry, I didn't want to go. All right. Yeah. All right. Let's see. What else? Is there any good wing place around here? Maybe Sunday I could spring for wings. Chris are up all the way. Let me know if there's something really good around here, you know what I mean? Okay. I don't know if I'll follow this that well. All right. Real quick introduction. Then we'll get into it. If you're not here to learn about me, we're going to learn about the end clicks are in. So just so you know a little bit about me, some of you, I'm most of you have never met me. Some of you have taken my class before and are here for a refresher. So that's cool. You also can do that. If you let's say some of you I know are from right today and some other places. You may not graduate till June. Somebody not graduate till June. Whatever. If you keep your receipts, you can come to any other review I have at no cost. Just show your receipt and you can come. You know what I'm saying? So you can keep refreshing. You know that kind of thing. All right. I am a registered nurse. I have been a nurse since 1973. So that means I've been a nurse for 36 years. How many words born would I graduate from nurses? So I've been a nurse for 36 years. So it's been good to me. It's been a great profession. I will have to admit that in 1973 in Youngstown, Ohio. That was the steel mill closings. We were in a really big recession up there and it took me three and a half months to find my first job as a nurse. But ever since then I've had minimum of two jobs going on at the same time. I've never been unemployed. Never lost the job. Always had at least two jobs going on. So it's a great even in an economic down time like is now your first job might be a little hard to find. But after that it works pretty well. So it's been good to me, good to my family. I love it. I like to teach it. So hopefully you'll enjoy it. I try to stay current as well, you know, in practice, work in nursing as well as teach in nursing. The last two years I haven't been able to work in nursing because these reviews have just taken over my life. I have every weekend, I'm somewhere. Which is, I'm not complaining. That's great. It's just, I'm going to start saying no to some reason eventually. See, I'm basically educated as a mensurge nurse, but I also teach psych and I work in psych so I know psych. I also do farm and I have graduate education and testing and measurement and cross-cultural nursing, trans-cultural nursing. Anybody ever hear of Madeline Lightinger? Some right-state people should have heard of Lightinger. Do you hear her? She's my advisor, so I'm an expert in cross-cultural and stuff like that. Let's see, I work a lot at ICU, a lot at ER, step down units. I usually have the idea that if something scares me, I go at it. So I was scared of Neuros, so I first started working in Neuros, then I was afraid of being able to read EKGs and rhythm strips, so I went into Cornere Care and learned that. And everything you can learn anything, just don't avoid. Don't go to everything you can't learn something or that something's too hard for you. Just go at it and you'll find it's not a big deal. See what else? I have a wife and four daughters. Yeah. I wish I had my cell phone up. It's Friday. There are teenagers that are going to be wanting money. They're going to have to shut up. They're going to have to put up a phone. But they're going to have to put up a phone. But they still do. I act my 20 and I got a phone call an hour ago from my insurance company. We have a claim of the State of New York from your daughter who spun out and hit up mile marker. And the State of New York has filed a claim on your insurance company to replace the mile marker. $1,200 to replace the mile marker. See? Give me a break. That's not happening, though you imagine. 20-year-olds insurance is going to go off to. But anyhow, I've got to know you here. Let's see what else. That's basically what I've taught at Cedarville University for 27 years. I'm sick of them. I'm sick of them. I'm one job, one wife. I'm just sort of sick of them. I don't like kids. If I could have gotten rid of the kids, I would have been stuck with them. No, I'm just kidding. But that's where I am. So we go around the room. You've got to tell them your name and it's not about nobody else knows about you. Oh, thank goodness. If she places it, do that. You know, go around the room and introduce yourself to them. We're not doing that. Okay. Forget it. Okay. What the goal is here. Well, we're together. I have three objectives. First, I want you to acquire some knowledge. I want you to learn something. I want you to go out that door and go, "Why? I learned something today." Because I don't assume that everybody knows everything. And it doesn't hurt to learn some new information every once in a while. And I know enough about nursing to know that every graduate doesn't know everything they could have known for this force. There's some information that you need to know for boards that you do not know. Now, it's different for everybody. Not everybody has that same deficit you have won that someone else doesn't have and vice versa. But I want you to acquire some knowledge. Some reviews you don't learn anything. All they do is they just do multiple choice questions. And you're learning how to apply it. Well, that assumes you know it. And you can't apply what you don't know. So a lot of good in it does sit there and try to apply something if you don't know what they're talking about in the first place. To me, that's a waste of time. And I've worked in nursing long enough education to know that students don't know everything that they probably shouldn't know. They've forgotten some stuff. So we're going to try to spit up your knowledge and I want you to acquire some knowledge. Secondly, I want you to gain confidence. I want you to, when you walk out of here, go, "You know, I can do this. This is something that I can do." Because I think one of the biggest fears that people have is that they're going to fail because somehow, some way, they're the one person in the universe that this is just beyond their capabilities. So to me, now everybody else will be able to do it. But they will not. For some inexplicable reason, it's beyond their capabilities. And the I got through school, and I got through that, but when I go to the boards, it's just going to get me those standardized tests. They're just going to get me. And you don't want to go there. So I want you to have confidence that you've done everything that you humanly, possibly, could have done when you sit down to take that board. Because the worst case scenarios, you go to boards. And you know, some of your friends, some of your classmates don't do any reviewing for boards. They just go take it. Well, that's okay. But can you imagine yourself, you sit down for boards, and you sign your name in, and you click go, and it brings up the first question. And suddenly you realize you haven't done anything to prepare for this. Could you imagine how you would feel if you had not done a thing to prepare? They may be your friends that aren't taking review classes might be confident now. I'd like to talk to them when that first question pops up and say, hey, you think you might want to do something, but then it's too late. So when you sit down and click start taking that test, I want you to realize that you've done everything you possibly could have done. And you did what is above and beyond reasonability, and you can have that confidence that you've done your part. Secondly, I want you to become exam proficient, meaning I want you to know how to take tests. Because earlier I just said you can't apply what you don't know, but you have to be able to apply what you do know. So it takes three things to pass boards, knowledge, confidence, and skill in taking exams. So this review is designed to address all three of those points. Have you acquired some knowledge, gained some confidence, and gained some exam proficiency? Walk out of here on Sunday. I want you to think, you know, I know how to do those select all employees. I know how to do those click and drags. I know how to do prioritization questions, delegation questions, staff management questions, best questions, first questions, all those kinds of different formats. I want you to be able to do point and click and all of those. So we'll be talking about that. I really believe that any review, there are two types of reviews out there. And if you've had reviews, you know this is some reviews just sit there and they give you a book that's an outline. And what do they do? They read it to you. I don't know about you guys, but I haven't enjoyed being read to since I was seven. You know, so I would just immediately go to sleep. And after the first break, I probably just leave figured I can read it at home. I don't need somebody to read to me. And then for a second. And then the other kind of review is like I said before, they have to see this whole bank of multiple choice questions. And all they do is they flash up on the screen and they say, okay, you got, you know, 30 seconds to do this question. So we're going to sit there, you know, and they say, okay, we're done. And of course, Susie anal retended over here says it's be, you know, and then all of a sudden now you guys your thought process is contaminated because she shouted out the answer. And now Jim is saying it messes up the whole process. And then you're supposed to learn from that. And then this person starts arguing with the teacher that they didn't think that was the right answer. And they take up 20 minutes arguing about some stupid question. And you're going, oh, let me out of here. And this is ridiculous. What's that? That's our flight. Okay. So it just to me, that doesn't need to one of those models works because two things. You can't apply what you don't know, but you have to be able to apply what you do know. And if all they give you is a lecture, you don't get a chance to apply it. And if all they do is apply, you don't get a chance to learn it. So I think the uniqueness about my review, if there is uniqueness, and I believe there is, is that it hits both of those. I hit a balance between applying and learning applying and learning. So that's sort of where we're headed, what we're doing. Now with the group size, we should be able to learn a lot. I sometimes have groups of 160, 170 people. So it's kind of hard to keep that all. But sometimes I have groups of 20. So it just depends. So this is about a small average, average size group, which is great. I like this size. I can keep in contact with you. Now I can't really see your eyes very well. And I always like to make some eye contact ever so often. But please ask questions. This is your chance to get things clarified. So ask me questions. There's probably not a question you can ask me. I haven't heard yet. Because after a while, there's only so many questions people can ask. So please ask. If I don't know the answer, I'll tell you where to get it. Let's see, I didn't know what I needed to say. We'll take breaks, 20 minute breaks. 10 minute breaks. Now here's the deal. I always schedule more time for these reviews than I have. No, I always schedule more time than I need for these reviews. So here's the deal. If 10 minute breaks are 10 minute breaks, we get out. We'll end up with extra time. Not because we didn't cover everything, but because the worst thing in a review is not to cover everything. So I always put an hour or two extra time on every day. If lunch becomes, instead of 45 minutes or an hour, whatever we decide, it becomes 20 minutes longer than that. Then we don't get, so I'm saying, what am I saying? To get back in your seat and get, we get started on time. We get out early probably. This I'm saying most likely. So you, you do have control of some of our finished time, our quitting time. I am assuming, and this is an assumption, you know, that's dangerous. What did you guys assume about a meal this evening, like 330 to 930? Did you plan a meal, who planned a meal in there? Who figured we'd just go straight? So how many figured we'd get was a meal, like four or three or four of you? Usually on the first day, we don't do a meal. We just go ten minute breaks. Now, isn't there a Wendy's over there or something? And they can zip over there and grab something and probably eat in here, although you probably not a lot of food in here. They're not going to cry about it, I don't think. Well, they cry about it. They won't say anything, so you can do that. Just don't squirt and catch up on your neighbor's book. That's all I would have. Okay, none of that. But tomorrow we'll have a lunch and Sunday we'll have a lunch and lunch. I depends on sometimes it's a half hour, sometimes it's an hour. It just depends on where we are and accessibility of food. Those of you guys that are from this area, Mount Carman, what would you say is a reasonably prudent amount of time for a group to size to get lunch and to be reasonable to expect them to be back? 30 or 40. What's that? We'll start with 45 minutes tomorrow and we'll see how it works. All righty? Okay, I'll plan for that. All right, and then what we'll do is, if everybody's sitting around doing nothing, we'll start early. We'll get out 15 minutes earlier when we would have otherwise. Question back here. The next scheduled one, I'm in negotiation with about eight places. Okay, the next scheduled one is in Florence, Kentucky, South of Cincinnati, about 25 to 10 minutes south of the airport. Or five minutes across the street from Turfway Park. You've ever been down to play the horses down in Cincinnati, but it's on March, March 26, 27, 28. Supposedly, I'm in negotiation with Ohio State for a review the week before that. And then I'm in negotiation with Central Ohio Technical College, possibly for a review sometime mid-March. And then Chamberlain wants me to come to review first week of March. But none of those, those are all Columbus areas. I also might put in a date and review second or third week of March. It just depends on how those all come together. So I can't, the website is the best way to look at, is it everybody been to the website? And that way, as soon as we know something set, we'll put it on there. So that's all I can tell you. I don't know otherwise. There'll be a lot in May. A lot in May. Any other questions? Any way this works is basically playing Bill in the Blind. You have your yellow book. And that's what we're going to do together. The blue book is, because people, years and years said to me, what do I do now? What do I do now? Reviews over, what do I do now? What do I do now that it's done? What do I do before, between now and when I take my boards? And I got tired of telling people, individually, what to do. So I made this blue book. I want you to do the blue book. Doing the blue book is part of the parcel of the review. If you haven't done the review book, you have not done a Mark Climax review. You've only done half of it. Because that blue book is a drill book to teach you facts, facts, facts, facts. When people don't pass boards, I usually sit down with them when they come to me and I'll sit down with them and see if they know what they're talking. And we will start doing some questions. We probably are 10 questions into that. And I've already taken them to the blue book like three or four times. Because they'll read something and go, I don't know what that is. Let's get out the blue book. There it is page 52. What's it say? So get that blue book out. The first question is somebody on occasion, people will take this course, not commonly, but on occasion. People will take this course and not be successful on the board. That happens to every review. There's no perfect review. If there were a perfect review, every other review would be out of business. The other thing is that, so what I do is if you would not be successful on your boards and you would want to talk to me about what to do about it. Do you know what the first question I would ask you would be? Do you know your blue book? Do you have your blue book up here? Then we'll talk. But you have to know your blue book first. Then we'll talk. So it's very important. I can't stress that enough. All right. I think I've covered a variety of issues. I can cover some things as we go if I can just do anything. I think most of the logistics are here. I usually lecture about an hour and a half before I give a break. Is that okay? Your nurses, your should have developed a biotic bladder just by now. Yes. Five years. Every five years it changes in content. Every five years in content. Every three years, they review past standards and percentages. There are going to be a few changes as of April 1 of this. What's that? Six weeks from today? April 1, there will be a few changes. But what's that? It could be very good for you. It could be a very good for you. Because the last time three years, you see, every five years they change content and they only change five percent every five years. So if they change the content, it's only going to be five percent of the content. Not the whole content. Just saying, everybody thinks that they change everything every five years. Well, that's people that don't know what they're talking about telling me that. They change five percent every five years. So in April 1, they will change five percent of the content. They will drop some issues, include some issues. I am. My book is designed to get you up until April 1. And then I have some changes in the book already for after April 1 as well. But I'm focusing on the ninety five percent and not the five. The other thing is they change that they evaluate the past standard every three years. And they're going to evaluate that April 1 as well. And that can be very good for you because the last time they did it, they made it higher. Now there's some talk that they'll make it higher this time. But people who really know are saying that they might bring it down. Because they were getting, they were having too many hot, too high a fail rates from schools all over the place. So I was saying, it used to be, it used to be case Western Reserve never had anybody ever failed. People from there failed. Christ possible, huge high pass rates. They were having bad times. So I was saying lots of schools that had traditionally done really, really well. A similar community college in Daytona stayed up pretty well. But a lot were coming down because they had up that standard. So there's a chance they might lower the standard on April 1. But don't delay taking it until after April 1 because you're thinking they might lower the standard because they may increase it. So we won't know that until they meet. But there's a victim because the failure rates went up since they changed it three years ago. There's pressure to bring the standard down. Does that make sense? All right, so about acid-based balance in ventilators. The first lecture. In the first page you'll notice a table of contents, some page numbers, and then some a blank alchemy left. What that is is that's for you obsessive compulsors to check off the lectures as we go. Because you have to have some way of knowing that you're accomplishing something. And if you aren't checking it off at checklist, you're not getting anything done. So that's for you guys. All right, the rest of us, we won't care. The other thing about that too that's helpful is let's say that tomorrow you are late and you miss two hours of lecturing. Well, if you're keeping your checklist, you'll know what you missed and you'll be able to talk to me about it and not tell you how to get that and how we would arrange for you to get that material you missed. But if you come up to me and say, "I'm just yesterday morning, what am I missed?" I'm going to go, "I don't remember. I'm just a talking head basically." So you keep track of where you're at. The other thing about this review is we're going to go out for better quality, which is kind of odd. Because most reviews go by specialty. They'll do all of pharmacology in one day. And then they'll do all met surgeon in one day. Then all peeds in another day. Then all psych, all at once. I don't know about you guys, but find out a five-hour review on pharmacology. I would be more confused at the end than I was at the beginning. Because it just can't jump like that. So I like to vary it up. And you've had all this stuff before. So I don't have to teach it in a coherent whole. I can bounce around. And I also want you to get used to bouncing around. Why? Because what does it do on the test? It bounces around. So I want you to get used to talking about med surgeon and jumping to some psych and just back to some peeds and then some ovian. And bouncing around so that your mind understands the principles rather than the specialty. Got it? Okay. And all you have to do to pass this test is do a little less than average. How many of you in here? Is it possible that you could achieve a little less than average on a test? So you don't have to do how well on this test. Do you have to do well on this test? No. Do you have to do average on this test? No. You need to do a little less than average on this test to pass. So don't think that you've got some insurmountable standard that you have to hit. And then you say, well, then why do people fail? Because they think they have to be up here. You see what I'm saying? And they stutter that way and they get anxious that way and it just doesn't work. Okay, acid base is something you do have to know about. If you do not know acid base, you are in trouble because everybody else knows about acid base. Okay, so one thing you have to do in acid bases, if they give you an archery of like acid value report, you have to interpret it as metabolic acid doses, metabolic outlets, respiratory acid doses, respiratory outlets. So if they give you a lab value, you have to convert it to words. Now, if you know how to do that, you're 100% accurate. Go for it. Don't listen to me. I don't want to fix what isn't broken. But if you're confused about that, you're nervous about it, you're anxious about it, I've got something here that might help you. Okay. All right, interpreting blood guesses. The first thing I suggest you memorize is the rule of the bees. Do you see it there? The rule of the bees. What I want you to do that is fill in here. It says if the pH that fills your first blanket, and as I say, there's only 3,000 to go. Okay. So if the pH and the bicarb, the pH and the bicarb are both in the same direction that it's meta-balling. So the bees are bicarb both-balling. Do you see those? Bicarb both-balling. The reason why this works is respiratory does not have a letter B in it. Bicarb has the B in it. So what I'm saying is this. They will give you an arterial blood guess with 8 values in it. How many do you look at? Look at the 8 values. 2. Which 2? pH and the bicarb. That's what the rule says. Just look at the pH and look at the bicarb. Then look to see what direction they're going. If they're both in the same direction, be it up or down, it doesn't really matter. As long as they're both in the same direction, who cares what direction? Then you must use what adjective. Metabolic. Because the rule says if the pH and the bicarb are both in the same direction, it's meta-balling. Well, what if they're in different directions? Then you only have one other choice and that's respiratory. Now what do you get the acidosis and alkylosis from? The pH. Exactly. So let's look at how this rule would work. Well, first we have to know the normals. What's the normal pH? 7.3 pi, 7.4 pi? That is a piece of universal nursing knowledge. Everyone knows that. If you do not know that you're the only nurse in the universe that doesn't know it. No, I'm serious. Okay, the normal bicarb is 22-26. Not a nurse knows that, so learn that. 22-26. I call them the bicarb years. When you're 22-26 year olds and you have to make all those decisions. What job do I take? Who's my buddy? Am I going to get married? Am I not going to get married? Am I going to move in, not move in? All those decisions you've got to make when you're 22-26. That gives you heartburn. So you need the bicarb. I call it the bicarb years because you're always in a knockover of decisions. It's nice to be 56. No choices. No other woman can watch it here. No jobs can watch it. It's nice. You only got a lot of options. Makes a nice question. Our teacher told us to remember that 2 plus 2 plus 2 equals 6. That's true, but what does that mean? Oh, okay, 2 plus 2 plus 2. Oh, 22 and 26. 2, 2, 2, 6. That's a lot of things. A lot of things. Bicarb. So 22-26. Now, let's look at those. And let's look at our examples. In the first example, the pH is in one direction. Down. Down. So draw a little arrow down in the box next to it. Then the rule says to look at what? The bicarb. And the bicarb in this case is in one direction. Down. So draw a little arrow down. Are those arrows going in the same direction? Yeah. So what adjective must you use? Metabolic. Metabolic. And because the pH is down, it is. So that is an example of. Metabolic. Metabolic. Okay, look at letter V. Bicarb is in, I mean, the pH is in one direction. Up. Bicarb. Up. Are they both in the same direction? Yes. Metabolic. So this is metabolic. Outlosis. Wait, is everybody with me? Okay, the next one. pH is down. Bicarb is. Up. No. So what adjective can you not use? Metabolic. So you have to use respiratory. So this would be respiratory astrosis. Now the only time this doesn't work is when there's a mixed astrosis order and boards doesn't go there. Because that's way too hard. All right. So if the pH is, is everybody see how the rule works? What if I gave you a pi, a pH of 7.50 and a bicarb of 25? 7.50 and 25. What would it be? Respiratory alkalosis. Why? Because the pH is in one direction. 7.50 and the bicarb is normal. 25. It's normal. 25. So is that the same direction? Up and normal? Yes. So it's got to be respiratory. So even if the bicarb is normal, it still works. So saying. All right. That's the ABG interpretation. Let's talk about sizes and symptoms. Let her be. They will ask, they will tell you a patient has respiratory acidosis. Metabolic alkalosis. Something like that. And they'll say, what would you see? Select all that apply. And you can hold laundry list to stop any of this. Select check, check, check. What's true? Well, two things here. One thing here. I hate lists. One thing you're going to see in my reviews. I do not have you memorizing lists of things. I hate lists. I despise lists. I refuse to remember. The reason why I hated lists in school was for two reasons. First reason I hated lists is, for example, if I learned 15 sizes of hypochalemia and then 15 sizes of symptoms of hypochalemia. When I took the test, guess what would happen? I memorized, I would remember the list word, or word I could reproduce the list, but I would forget which one was which. You should say. And when that happens, you're dead. How about work, weapon, for nothing? The second reason why I hated lists was, even if I could remember which was which, and all 15 sizes, my teachers had the tendency to pick size number 16, 17, 18, and 19. And not the 15 that I memorized, and one thing that you guys learned really early in nursing is every book says something different, right? Take two nursing books. Same thing. Look at the list. The lists aren't the same, right? We are fine, two found two lists, we're the same, for anything in nursing? Never. So you can memorize a whole bunch of lists, but for that to be productive on boards, it better be what? The list that boards is using, right? And what chances is, as that, very slim. So the point is, this boards does not test your knowledge of lists. It does not. What boards test is your knowledge of principles, not lists, but how will they test your knowledge of principles by having you generate lists? Do you understand what I'm saying? Boards will not test your knowledge of what? List. They test your knowledge of, but they will test your knowledge of principles by having you generate lists. And so when people take boards, they say, oh, you got to memorize a whole bunch of lists. No, you don't. They don't know what's going on. For example, in general, what do pain meds do? In general, what do opioid pain medications do in principle to a person? What do they do? Basically, they do, don't they? They're CNS depressors. Okay, now, they will ask a question like, your patient is on delotted and opioid analgesic. What other following things would you expect to see if they got too much or that they, you know, were getting a little too much? Select all the plot. Alrighty? And you're thinking, oh, my goodness, I don't remember the list of delotted, it's not a list of delotted signs. It's to see if you know that opioid analgesics are CNS depressors, so when you go to the list, what do you select? Agitation or lethargy? Placidity or spasticity? Reflexes of plus one or plus four? Plus one, hyperreflexia, hyperreflexia. You know, restlessness or obtunded. Well, you go, I know what restlessness, that's up, so obtunded must be down. That's a good test taker right there. Okay, and you say, I'm tired of it. Yeah, a good test taker never says, why? They say, hmm. And then they figure it out the other way. Think about you guys that are good test takers, you haven't figured out that those good test takers, they don't know anything. They're not, they don't know any more than you know. In fact, they probably know less than you know. They just don't quit, they just figure out, I'll get it. They won't let me in the front drive, go in the back door, the back door is closed, I go through the seller window and they'll figure out way to get out. They just don't quit. Port test takers go, oh, I don't know what that is. No, I assume it was really bad test taker. He came to a maternity question and it said, what's the best way to treat morning sickness in a first trimester woman? And he said, oh, this is the only OB had a question I know the answer to is crackers. He was so excited and he got the one OB thing he did not. So it's crackers crackers, he looks a didn't say crackers. He didn't say crackers. He didn't say crackers and he didn't say crackers. And what did he say is a bad test taker. What did he say? Oh, my goodness, I thought I one knew this. I guess I don't know this. So he picks something like an absence every half hour. Okay, and then he wonders why he doesn't do very well. What do you know what number C said? Do you know what answer number C said? Drive, carbohydrates. Well, it's just like carbohydrates. But what did he do? He was expecting the front door, crackers. No, you go the back door, dry carbohydrates. So I'm saying, don't give up. Don't think that you don't know this. You know it. So if they say restless versus of tundered, you know what restless is. I'm tundered. Must be the other. Okay, but you see what I'm saying about the sedation and you generate the list by applying the what principal not having memorized some list. Why can't boards test lists? Why can a national nursing test not test lists? Because why all the lists are different in different text books in different geographical areas of the nation. So write a statistically significant, reliable, valid question. You have to write the question so that no matter who takes it, no matter what book they read, no matter what school they went to, it's a fair question. And if you're just taking out of most of these book on whatever the signs and symptoms and whatever, you write a question that it will perform horribly, statistically, nationally. The only way you can do these select all the lies and have them perform well is to test what principles and see if a student can generate a list from a principle. Does that change the way you might look at it, select all that apply question? You understand what they're about? There is no mystery. You weren't supposed to have memorized some mystery list that you didn't know. You're supposed to say, this is a chance for me to show I know a principle. You got that? That's how you do notes. Okay. So I want to give you a principle for answering acid-based signs and symptoms. And it's what's in the box there. It says, as the, see where I'm at. As the pH goes, so goes my patient. What? What does that mean? As the pH goes. The pH can go up or the pH can go down. And when the pH goes up, your patient goes up. And when the pH goes down, your patient goes. Does that mean they sink and levitate? What does that mean? What's it mean? So when the pH goes up, every system in your body gets more irritable. But when your pH goes down, systems in your body shut down. So when your pH goes down, you shut down. When your pH goes up, everything gets hyper excitable. It's pure chemistry. It's talking about catalyzing chemical reactions, basically. So do you see where it says, except for potassium. Sorry, I didn't write that in there. Except for potassium. So what does that mean? When the pH goes down. And when the pH goes down, potassium goes up. Because if it follows the rule, we wouldn't even mention it, right? So when the pH goes, so goes my patient, except for potassium. So if your patient goes up, do you see the little box that says up? What is that? What's an other name for that? Up pH. Alkalosis. What will you see without galosis? Give me some stuff. Give me some signs. You see without galosis. Irritability. Absolutely. Hyperreflexia. What would be some numbers that would be hyperreflexia? What numbers? Three and four. Three and four are hyper. Two is normal. One is zero. Our hyper. Remember that with reflexes. Three and four are high. Hyper. Two is normal. Reflex. And one to zero is hyporeflexia. What else would you see with alcohol? You got two of them. We got irritable. We got hyperreflexia. What else do you think? Think of a body system and then go high. Tachypnea. What else? Tachycardia. Would you have paralytic Ilius or Borboregmy? Good. You could test take your sick Borboregmy. Even though you may not know what it is because paralytic Ilius sounds like everything is shut down. That would be the down. The up would be Borboregmy. Now boards loves the word Borboregmy. B-O-R-B-O-R-Y-G-M-I. Borboregmy. That is the word they will use for increased bowel sounds. So if you hear somebody's stomach growling this evening, what will you say? How Borboregmy? Borboregmy increased bowel sounds. Can you spell it one more time? B-O-R and do it again. B-O-R-Y-G-M-I. Borboregmy. So what would be down? Acidosis and what would you see there? What's that? Hyporeflexia. What else? B-O-R-Y-G-M-I. Lephyrgy. By the way, ob-tunded means just one step more levargic than lethargy. O-B-T-U-N-D-E-D-ob-tunded. Vocabulary is critically important to pass this test. That's why the blue book and the yellow book are real heavy on blue book vocabulary. Can I ask a question if you don't know what the words mean? Sounds pretty obvious. So what would you have? Parallelicillus or Borboregmy? Parallelicillus. Would they have a seizure or a coma? Coma. The seizure is up. Coma is down. You gotta go the same as the pH. So let me ask you this. What acid-based imbalances are most likely to C's and which ones are most likely to have a respiratory arrest? Apolosis will what? C's and acidosis will respiratory arrest. Does that make sense because you're doing it as the pH goes, so goes your patient? So what acid-based disorders need an ampoule bag at the bedside? What acid-based imbalances need an ampoule bag at the bedside? Acidosis because they're gonna what? Respiratory arrest. Which acid-based disorders need suction machines at the bedside? Apolosis because they could, C's and aspirate. Don't limit yourself. When they start asking these things, they say, "Wait a minute. I know about this. I can get there." See, I shouldn't have to teach you who needs an ampoule bag at the bedside. You should be able to get that from as the pH goes, so goes my patient. Do you see what I'm saying? These rules use them. They're tools. Before we turn the page, I want to ask you, I want to introduce you to, uh, whoa. Don't look at the light. Is that coming clear? I want to introduce you to my favorite Scotsman. Now Scots' surnames have Mac, Google, MacDonald, MacGyver, M-A-C. You know, my favorite Scotsman, Mac, who's not? How many are for the cruise balls? Okay. From now on, I'll wait. Every time you see a cruise ball, I want you to think, "Why?" Mac, who's not? In fact, if you're talking to a doctor, he goes, "These Mac, who's not?" I'll be happy. It'll make them a stupid, but I'll be happy. The reason is, is cruise balls is a compensatory respiratory pattern for one, an only one, acid-based disorder. You only see cruise balls with one of the four metabolic disorders, one of the four acid-based disorders. Which one? Well, Mac tells you that. M for what? M-A-C for an acidosis. So Mac, who's small, tells you that you see cruise balls with metabolic acidosis. Okay, we have some knowledge, but we have to be able to what? Why? You can't apply what you do not. No, but what you know, you have to be able to. This says, "Your patient has respiratory acidosis, select all that apply, plus one reflexes." Diarrhea, a dynamic illness, spasm, urinary retention, paroxysmal, atrial, tachycardia, second degree, MOVITS, type 2, heart long, and hypocalemia. I want you guys to get in groups 2 and 3, right where you're sitting, you know, from MOVITS. I want you to talk to somebody, everybody, and I want you to answer this question. And I want you to use the rule that I taught you. The rule is like, as the pH goes, so it goes by patient, except for potassium. Now, I really want you to draw some arrows here. I want you to draw arrows. Okay, and I want you to get the answer. So you can do it yourself and turn to your buddy, discuss it, and then we'll talk about it. And don't see any answers out loud. Get it over with now. So we're choosing which ones. It means that select all the apply. So we're choosing what is respiratory acidosis. All right, so knowing that as the pH goes, so it goes by patient. I'm going to say that. I really want you to go on. First one would be down. So it would be down. That would be high. So that is a whole family me. Wait, but now that's different. So that's except for potassium. So if it goes in, that means that potassium's up. So I guess it would be down. Low is down. So it would probably be that. Okay, I want you to count the number of things selected. Don't say, if you have good, I'll ask for it later when we count our numbers. Yeah, what? Down is zero to one. Okay, not many of you selected. So let's play our game now. What should you automatically notice about this question? What does the pH is in what direction? And everything's going to go in the same direction, which is what direction? Except for potassium, which is going to go. So I can. So now there's your answer now. Up or down. Select or no select. Yes. Up or down. Select or no select. No. A dynamic without movement. Up or down. Down. Select or no select. Select. Spasm. Up or down. Select or no select. You're in a retention. Down. Select. Car says what angel type of card is. Select or no. No. Moves type two hard block. Yes or no? Why? Block means the impulse is being what? Slow. Blocked. Down. It's being hindered. So that's a select. Hi polimium. No, I want a high K. Not a low K. So the answer is the plus one reflects the a dynamical is the younger retention and the second degree of moves type two hard block. How many got that right? Excellent. Excellent. Did you memorize the list? No. How long would the list be before you got second degree moves type two hard block? Right? So that's what. And they're testing what principle? What principle are they testing? Then in an as a dot of environment chemical reactions cease. So everything shuts down and that's why you tell it say. There you want to have memorized these. Do you want my point is. So this is kind of free you from fear of these select all of the blocks. Well, by the way, what's the number one prop mistake that people make was select all apply most common state made was select all apply questions. Selecting one more than you should have selected number one problem. Now those of you who are real concrete people. I did not say answer what you think and take away one. I didn't say that. I said that the tendency for people is to answer what one more than they should. So here's the deal with the select all of the flight. If you know it's two of them, what do you do? Select those two and what? Stop. Because if you go, well, you know, it could be. Okay. Now that's a killer on select all the plot. You know, could be don't go there with select all apply. I was not cruel because you're heading down a road that's going to get too long. If you do not know that it's an applies, do not answer select all of them. If you don't know that you don't know that this is true, then don't pick it. All right. The other thing about select all of the flight is never only one and it's never all of them. Just saying, never answer just one on a select all of the flight and don't answer all of them on a select all of the flight because it's never one and it's never all of them. Okay. Let's go to the next page. Causes of acid base amounts. Causes. What they'll do is they'll give you a scenario and they'll say, this is what's happening to your patient. And then they'll say what acid base disorder would result from this? Do you see there? They're flipping them. They're flipping it around. Instead of saying what sign in symptom will the acid base balance cause? They're asking what will cause the acid base amounts? And one thing that people do wrong when they answer these kinds of questions is they get signs of symptoms and causation messed up. Do you realize that in the human body, often times what causes something is the opposite of what the signs and symptoms of that they are? Does everyone understand what I'm saying? So a lot of times what will happen is diarrhea will cause a metabolic acidosis. But once you get acid done, it will shut your vowels down and you will get a paralytic illus. Do you see what diarrhea caused? Did paralytic illus results from it? It's the opposite. And when you're sitting there going, man alive, I learned it was this. And now you're telling me the opposite. Probably what do you mess enough? Causation versus sign in symptoms. So make sure that you, many times if you go back and you do questions now and you get confused. Wait a minute, are you talking about signs of symptoms or are they talking about causation? Then you can go, "Oh, I see where the problem is." So you understand that? Okay, so just keep that straight. Okay, having said that, we're talking about causation now. Whenever you get a scenario, the first big question you ask yourself is, is it lung? That goes in the first blood. Is it lung? L-U-N-G? Is the scenario a lung scenario? If the scenario they give you is a lung scenario, guess what kind of a problem it is? It's respiratory. I mean, it can't be any easier than that. However, that only gives you a 50/50 because it could be respiratory acidosis or respiratory acidosis, correct? Well, how do you tell between those? Well, the second question you ask yourself is, is the client over ventilating or under ventilating? Is the client or patient over ventilating or under ventilating? That is going to be critical for your respiratory. If the patient is over ventilating, pick alkylosis. If they are under ventilating, pick acidosis. Now, this is extremely simple. It's almost pathetically simple. Are these not the only four options you have to choose from when you combine them to make these imbalances? It's either metabolic arrest or it's either acidosis or acidosis, right? So, you're choosing between these four words, correct? Well, let's look to see how this works. If the client is over ventilating, let's take a word ventilating. Which of these three words fits best with the idea of ventilating? Exactly. Now, we're left with what? Over of the remaining three words, which word has the closest connection to something being over? Why alkylosis? Because it's over the normal. So, that's alkylosis. So, if you put them together, ventilating over becomes respiratory alkalosis. See how easy that is? And if I say that the patient is under ventilating, what does vest become? Respiratory. What does under become? Asked because that's under the normal. So, under vet becomes respiratory acidosis. You see, you're just translating. You're just translating. Let's see that. How many understand what I'm saying? Do you see how easy this is? You're simply translating. So, when they say over ventilating, you say, "Oh, respiratory alkalosis. Under ventilating, respiratory acidosis." So, let me ask you this. They give you a scenario where a woman is over zealously using her breathing techniques during labor. She's really over zealously using those breathing techniques. What asked the basis, sort of, which she exhibits? Was that long? Yes, she's over -- she's breathing techniques. Over zealously using breathing. So, that's long. Is she over ventilating or under ventilating? Over ventilating. You translate that to mean respiratory alkalosis, and that would be your answer. You have a child who was a victim of near drowning. What asked the basis, sort of, would it be? Well, is that a long scenario, near drowning? Yes. Would the kid have been over ventilating or under ventilating when he was nearly drowning? Under, so he would have respiratory acidosis. Your patient has hemphysema and air trapping. Is that long? Is he over ventilating or under ventilating? Under, so he would respiratory. So, be careful, ventilating doesn't mean respiratory rate. The respiratory rate is irrelevant here. Everybody pays way too much importance to the respiratory rate. The other side of the ventilation has to do with gas exchange, not respiratory rate. For example, I could say that a person had pneumonia in five loaves and there are four loaves in the law. Nemonium, four loaves, they're breathing at 50 a minute, and their SAO2 is 78 on eight liters per mass. You got what they have. Nemonium in, four loaves, breathing really fast, but their SAO2 is really low. Now, is that person over ventilating or under ventilating? Under, even though their rate is 50, because rate has nothing to do with it. And everybody pays so much attention to rate. They miss these questions right and left and under don't understand why. Because your pain attention to the wrong piece of information. It's not about the rate. It's about the SAO2. If you agree with me that if your SAO2 is good and you're breathing slow, you're fine, but if you're breathing fast and your SAO2 is low, you're actually under ventilating. So, the rate can be tricky. So, what am I trying to tell you? When you get asked the basis order questions, what piece of data in the question is real shaky to use to get your answer? Restory rate, because a lot of times it compensates, which means it does the opposite, so you'll totally get the wrong answer. Pay attention to what? SAO2. Somebody's on a PCA pump. What acid-base imbalance would tell you that maybe they need to come off that thing? They're on a PCA pump. What acid-base disorder would tell you they need to come off that thing? Well, you say, "Okay, well, what do we know about PCA pumps?" Say what? Depress? Respirations. Why would they need to come off of it if they were getting too much, which would make my respiratory rate go really what? My dental aces go really down, which would mean I would be under ventilating, so the answer would be respiratory acidosis. So, respiratory acidosis would tell you that maybe you need to back off that PCA pump. Does that make any sense? And see, those are questions you may not have even thought you know the answer to, but you can get the answer if you just calm down and use it, because this is a lot. It's a tool. So use the tools if you're just both. Don't say, "I can't get the screw out and the screwdriver is still sitting in the box." Grab the screwdriver and try to get it out. So many times I teach people tools on how to take tests and everything, and then I do test questions with them and they lead the tools in the box. Get the tools out. Start using them. What if it's not long? The next box says, "What if it isn't long?" It's a metabolic. It isn't long. It's metabolic. Well, good news. There's really only one scenario where you will answer metabolic alkylosis, and that's what the next fill in the blank says. It says, "If the patient has prolonged gastric, vomiting or suctioning, pick metabolic alkylosis, why?" Why does prolonged gastric vomiting and suctioning lead to metabolic alkylosis? You're losing acid. If you lose acid, you become basic. Otherwise, everything else that isn't long, you pick metabolic acidists. For everything else that isn't long, that's another fill in the blank. Everything else that isn't long, pick metabolic acidists. The patient had GI surgery. He has had an NG tube to low intermittent gonco suctioning for three days. What acid-base disorder would he most likely exhibit? Metabolic alkylosis. Your patient has hyper-emesis-scravid darum. What acid-base disorder are they most likely to exhibit? Metabolic alkylosis. Your patient with hyper-emesis-scravid darum is now dehydrated. What acid-base disorder would they have? Now they've gotten dehydrated. That's not prolonged gastric vomiting, especially. It's something you see with it, but it isn't what it is. So now, what would they have? Metabolic acidists because they've caused that. Yeah, it flipped on the other side, and now you're there. Good point. What about this? A person who has acute renal failure. What acid-base disorder? Acute renal failure. Why metabolic acidists? Why? You're right. The why? Is it lung? No. Is it vomiting or suctioning? So it's got to be metabolic acidists. Is everything that isn't lung or vomiting or suctioning is metabolic acidists? What about infantile diarrhea? Metabolic acidists is why. It's not lung and it's not vomiting. That's the other end. Diario. Okay. What about third degree burns over 60% of the body? Third degree burns over 60% of the body, first phase. What? Absolutely. Metabolic acidists because it's not what? Mung. And it's not vomiting or suctioning. Okay. What acid-base disorder do you see with idiopathic bullet's pimp against? What? Yeah. Metabolic acidists is very good. Why? I mean, I don't know what it is. It is lung though. But if it is lung, I mean, you know, it's only you got one spotty system out of 13. Right? And if it's on your suction, you've got one out of 1,000 symptoms. So when you don't know what it is, what's your answer? Absolutely. Metabolic acidists. Everybody, right now. Right now, as you're sitting there, I want you to set your default set it for answering acid-base questions to metabolic acidists. Okay. Everybody, do it. Okay? Do it. So when you. What do I never want to hear? I never want to hear you guys go. Oh, I don't know what acid-base disorder is because I've never heard of that disease. That's when you absolutely do know what it is. I've used that rule for 20 years. I take the acid twice a year. I take ATIs. I take Kaplanjunk. No, stop. Kaplan quality materials. And I do. I do every book that's published, everything that's there, I do that. Why do I do it? It's my job to prepare for you guys. I better know what's out there and I better know what's current and I better know how it's being tested. So if it's been published, I've done it. I've even been to the NCSBN site and done their questions. So I know what these questions are. Every time I don't know on an acid-base question, what does Mark Clement think? And he's 100% right, everything. I have never missed a question using that. All right? What do you have to know for acid-base? Well, what you have to know is if the pH and the bicarb are both in the same direction, it's metabolic, as the pH goes, so goes, my patient except for potassium, maccus mole, over ventilate, under ventilate, translate, vomiting, or suction, metabolic alkylosis, everything else is metabolic acidosis, if I don't know what's a big metabolic acidosis. That's acid-base. It's all you have to know. So say it with me. If the pH and the bicarb are both in the same direction, it's metabolic, as the pH goes, so goes my patient except for potassium. Okay. Over ventilate, under ventilate, translate. What do I mean by that? Yeah, translate. Over ventilate is respiratory alkylosis. Under ventilate is respiratory acidosis. If it's vomiting or suctioning, pick. Metabolic alkylosis, for everything else, pick. Metabolic acidosis, and when you don't know what's a big pick, pick. Yeah, I use that all the time. That works for you. Okay. Those are helpful tools that work. All right. Yes. So this one just makes this clear that one question you asked is, yes, the bare body, and you've gotten dehydrated now, as we look at the G, the dehydration. Right. There's a rule in test-taking. So what was the rest? Yeah. When you want to get a question right, you always pay more attention to the modifying phrase than the original noun. Do you hear that? You always pay more attention to the modifying phrase than the original noun. So a person with obsessive compulsive disorder, who is now psychotic? What's more important? Psychotic than obsessive compulsive disorder. A patient with vomiting, who is now dehydrated, the dehydrated takes precedence over. So the modifying phrase trumps original noun. So people get caught on that air of free time. Boku questions. They've crashed and burned on that. Because they're focused on original noun. It's gone past original noun. It's now modifying phrases what the question's about. Good question. Okay. Let's talk about ventilation. We'll take a break. Ventilator. The first two things you have to know is the alarm. You have to know the alarm systems, and you have to know how the blood gases articulate with ventilators. There's a thing called a high pressure alarm. A high pressure alarm is triggered by increased resistance to airflow. Increased resistance to airflow. In other words, the machine is having to push too hard to get the air into the lungs. It's having to push too hard. There's resistance. And when that happens, the machine will set off a high pressure alarm. Because you understand, when you set up events, you set up two alarms. You say, "I don't want you to use less than this pressure to get that air in." And I don't want you to use any more than that pressure. You tell about that. And then when it exceeds that, the high pressure alarm themselves. See, if you set the high pressure at 40 millimeters, a mercury, you say, "I don't want you to push." The machine? I don't want you to push any more than 40 millimeters of mercury to get that air in. If the machine has to, it will set off the high pressure alarm. Because it's telling you, "It's too hard. I'm having to work too hard because it's high pressure." Does everybody understand that? Conceptually. Okay, now, what would it be due to? Well, obstructions. There are three obstructions. Number one, kinks in the tubing. The tubing could be kink. Would that increase resistance? Sure. So what do you do for that? That's rocket science. Unkink. Okay. Then, second most of the common obstruction is water condensing within the tube. There's water condensing in the dependent loops. Another more rocket science here. Empty it. And the third most common cause is mucus secretions in the airway. They've got goop there. Don't jump. And what do you do for that? Now, what will be suction is correct, but what would you do before you suction? And I'm not talking about preoxygenating. Is that just true? But is there another strategy that would be done to mobilize secretions before you would actually suction the person? What would you do? Change position, turn, cough, deep breathe. So you would do that first. And if that didn't work, what would you do? Stuction. What do you guys know about suctioning airways? What do you think? Good, bad, otherwise, what do you think? Give me your impression. The more you do it, the more secretions the problem should cause. So it's a double-edged sword. So how often do you suction patients? Every 15 minutes, every two hours, every four hours, or none of the above. None of the above. How often do you suction people? That's necessary. And that means when they cannot mobilize it after they've been turned and coughed and deep breathed. In ICU, I'm notorious for beginning. Nurses always negatively talk about me in ICU because I don't do much suctioning, but I do an awful lot of turning. And I find if somebody's O2 sat low and they're tacking and they're looking like they need, I don't get good air exchange and the high pressure alarms are going off all the time, I turn them. Patient coughs and whack, it outcomes this thing, hit the wall on the other side. And then they pink up and they're just fine, thank you. And I never did suction it. And I'll go in and report and say, "How many times did you suction him?" I didn't suction him at all. How come you never suction people? Well, his O2 sat is 98 on room air. You got a problem with this? Just show us these lungs are clear. It's got 98 on room air. Temperature is normal. You got a problem? Okay, so I do a lot of turning man. I do a lot of turning and confident deep breathing and I find I will do a whole lot of suction. Some people yeah, but not as much. Okay, so that would be a click and drag. What do I mean by a click and drag? Order. What would you do first? High pressure alarm goes out. What do you do first? What do you click first? Unkink, check for kinks and unkink, click it, drag it, drop it. Then what would you grab second? Empty water out of tubing, click, drag, drop, then what? Turn, cough deep breath, click, drag, drop, then what? Subtion, click, drag, drop. That would be your order. Turn the page and let's talk about more pressure alarms. What's this saying? Decrease resistance. Remember, I told you you always set a low level. If it is below that, there's decreased resistance. So when the machines say, that was too easy. Yeah, I had to work too little. That was way too easy. Push in that breath in. Well, what do you think would cause a low pressure alarm? Decrease resistance. Disconnections. There are two disconnections you need to know about. The first one is disconnection of the main tubing. If the main tubing is disconnected, what do you do? Yeah, it's more rocket science. Reconnect. The other most common disconnection is the oxygen sensor tubing. What is the oxygen sensor tubing? What is that? Anybody know? It senses the FIO2 right at the tray area or the airway area. What does it look like? Anybody know what it is? It comes from the ventilator machine. It's a black coated wire. It's very small. It's probably about half the diameter of your pencil or pen that you're using there. It goes right along the tubing, piggyback in it, along the tubing. It comes right where the tray or the end of the tube is, and it kind of hooks. Do you have a computer where you take the cord in? You hook that little cord in there. It makes a right angle. You have one like that. Well, it's like that. It hooks into that hole in the tubing. It measures the FIO2, the oxygen delivered right there. But if that pops off, when the air comes in, what's it do? Because out that tube, it's better into them and there's less resistance. Do you see how that would work? So, will you have to just take that sensor and plug it back in? Because so many nurses, they'll be going long, long, long, low pressure. They're going, "But it's connected. It's connected." And here's the wire hanging down, and they don't see it. So, reconnect the main tubing, then reconnect the oxygen sensor. Those are the two most common problems. So, in general, what are high pressure alarms due to? In general, obstructions. In general, what are low pressure alarms due to? Disconnections. In LPS, this is the same as RN. You have said the RN test LPN is the same information. It's just from a different perspective. For example, I think RN question would say, "You have the following four patients. Which one would you assign to an LPN?" The LPN question would say, "You have the following four patients. Which one would you accept as an assignment from an RN?" It's the exact same four people, just looking at it the other way. So, you really do LPN's and RN's need to know basically the same kinds of things. They just need to know the difference in the scope of that practice. In some ways, no, I won't go there. Okay. What about acid basis? Respiratory alkylosis. Respiratory alkylosis means the ventilator settings may be to what? Why did you say that? We can turn respiratory alkylosis into another word. What can we turn it into? Respiratory. Ventilating. Alkylosis. Over. So, then you write and read it. Over ventilating means the ventilator settings may be to see how easy it is. All you do is take these acid basis orders, turn them into just normal words, and the answer will jump off the page acting. So, what is the other word for respiratory acidosis? Under ventilating. So, under ventilating means the settings are to look. Did you got that? Now, how would this be applied in a question? And this will do this question and then go to a break. The doctor says, "Ween off vent in AM." Got it? He's writing it today for tomorrow. Ween the patient off the ventilator in the morning tomorrow. The 6 a.m. ABGs show respiratory acidosis. What would you do? A. Follow the order. B. Call respiratory therapy. C. Hold the order. Call doctor. Or D. Begin to decrease the settings. What would you do? Talk to your wife. And LPNs, it would be wherever it says, wherever it says called doctors, you could put notify RN. What's your answer? The answer is C. Why did you know it was C? He's under ventilating. How do you know he's under ventilating? It's got some stress. So, does he need this ventilator? Oh, yeah, he does. Is he being under ventilated on the ventilator? He's already under ventilated on the ventilator. Am I going to take him off the ventilator? He's going to be even worse. So, what acid base disorder did you want to see at 6 a.m.? Respiratory alkalosis, which means he's being over ventilated. In that case, he probably doesn't need a ventilator. So, is this hard and easy? I told you you've got to get a bunch of questions on ventilators and acid base and how you use your acid base to know what to do with ventilators. How many of you are going to go like this? How many of you see it's not really hard? It's very simple. You can be with the acid base. Why is B about acid? Yeah, never pick an answer where you don't do something and somebody else has to do something. You may feel like doing that, but that isn't the answer. Okay, that's what I call the chicken answer. You know, you're trying to spread the calls so you have a respiratory therapy. So, the patient says to you, I have cancer. I only have six months to live. Do you think there's a heaven or a hell? Where do you think I'll go when I die? What would you do? Do you not pick called chaplain? Now, you may not feel like you want to deal with that right then and right there, but as a nurse, you're supposed to say what? What do you think about Jesus, what I'm saying? Not the answer. You know, you're going to hell. How's the patient feeling? Don't tell anybody to see it when I said that. Okay, take a seven-minute break. You guys have been really good. And we'll come back at 25. We'll go for a second. We'll do the right thing as far as we can. Okay. Yeah. Oh, yeah. Okay. Okay. Did you write the one down about the game? Third degree version of six-something body? Yeah, it made about it.