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Mark Plummett is leading a review session with Linda Kaye available for logistics questions. Participants are urged to have blue and yellow books. Shannon and Derek are thanked for organizing. Lighting issues are discussed. Restrooms and food arrangements are mentioned. Mark shares his nursing background, teaching experience, and personal life. He emphasizes the importance of acquiring knowledge during the session. No personal introductions will be made. Mark aims for participants to leave having learned something valuable for their nursing boards. I'm Mark Plummett, and I'll be doing the review, and Linda Kaye is out at the table. She'll give 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, I'll just refer you to her and just go to her program. She'll be here today and probably tomorrow and probably Sunday, but I'm not exactly certain on Sundays. She may or may not be here. 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 and get that done. I'd like to thank Shannon and Derek for all their work getting this organized. What you did is a lot of work, and I appreciate it. Thanks, guys. A lot of work. And basically, it's like two weeks' time. I know professional event planners that can't pull off anything unless they have six months. You guys ought to go into event planning if you'd like to. We have a passion for it. So, here's our first release. The lights, we don't know anything about the lights. No, I tried getting them back on. We have some functioning. Are they even trying or did they just... Exactly, they come on and we need to get them back on. So, they're not going to try to fix them? No, not really. So, we're going to be... Yeah. Now, is that sunlight or is that ambient light? Ambient light. That's true. I was going to say, if that's sunlight, when it goes down, it's going to be a little dark. But hopefully, it's just backlighting. Do you think that's what it is? Yes. Okay, good. Well, that will give us some lighting. My eyes actually are... When I first came in here, they seemed pretty dark in here, but actually, a lot 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? Can you hear me? Of course, if you didn't, you wouldn't answer anyhow. So, I guess that's a stupid question to ask if you hear me or not. But I don't usually use microphones because I don't usually need a microphone. But if 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 auditoriums this size and bigger without microphones, and my voice usually lacks. So, it should work. Logistics, there are men's and women's restrooms right out to the left, for those of you who aren't from Mount Carmel. Well, anybody can use them. I'm telling those of you that aren't from Mount Carmel where the restrooms are. There are separate restrooms for Mount Carmel people. But watch what I say. People take me literally. Also, there are chips and salsa out there, I guess. And then tomorrow, Shannon's arranged for pizza to be brought in for lunchtime. And so, you can plan on that. And if you wanted to bring some extra little things to throw on the table, that would be fine, too. Is that correct? Right. Okay. Let's see. Shannon, anything else I needed to tell them from your information? No, we are planning on a hot list. So, if you want to, if you need a great speaker who can speak with you and bring something that you need as far as an audio book. All right. All right. Let's see. What else? Is there any good wing place around here? There's something I can spring for wings. For example. Let me know if there's something really good around here. You know what I mean? Okay. All right. Real quick introduction, then we'll get into it. You're not here to learn about me. You're here to learn about the NCLEX-RN. So, NCLEX-RN is a program that's designed to help you get started. It's designed to help you get started. It's designed to help you get started. It's designed to help you get started. It's designed to help you get started. It's designed to help you get started. It's designed to help you get started. It's designed to help you get started. It's designed to help you get started. It's designed to help you get started. It's designed to help you get started. It's designed to help you get started. It's designed to help you get started. It's designed to help you get started. It's designed to help you get started. So, just so you know, a little bit about me, some of you, most of you have never met me. Let's say that some of you, I know, are from Wright State and some other places. You may not graduate until June-ish. You may not graduate until June-ish. You may not graduate until June-ish. You may not graduate until June-ish. You may not graduate until June-ish. You may not graduate until June-ish. You may not graduate until June-ish. You may not graduate until June-ish. You may not graduate until June-ish. You may not graduate until June-ish. You may not graduate until June-ish. You may not graduate until June-ish. You may not graduate until June-ish. You may not graduate until June-ish. You may not graduate until June-ish. You may not graduate until June-ish. You may not graduate until June-ish. You may not graduate until June-ish. 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. 36 years. So you were born the year I graduated. How many weren't born when I graduated from nursing school? Okay. 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 closing. 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 a minimum of two jobs going on at the same time. I've never been unemployed, never lost a job. Always had at least two jobs going on. So it's a great... Even in an economic downtime like it's 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. 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. Every weekend, I'm somewhere, which is... I'm not complaining. That's great. It's just... I'm going to have to start saying no eventually. Let's see. I'm basically educated as a med-surg nurse. But I also teach psych, and I've worked in psych, so I know psych. I also do pharm. And I have graduate education in testing and measurement and cross-cultural nursing, trans-cultural nursing. Anybody ever hear of Madeline Leidinger? Wright State people should have heard of Leidinger. Did you hear of her? She was my advisor. So I'm an expert in cross-cultural and stuff like that. Let's see. I work a lot ICU, a lot of 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. And I was afraid of being able to read in KGs and rhythm strips, so I went into coronary care and learned that. And everything, you can learn anything. Don't ever think you can't learn something or that something's too hard for you. Just go at it, and you'll find that it's not a big deal. Let's see what else. I have a wife and four daughters. I'm going to shut my cell phone off this Friday. They're teenagers. They're going to be walking away. I'm going to shut off the phone. I'm going to shut off the phone. There. Now they're going. They have four daughters. They're 22, 21, 20, and 12. So we're just getting out of this teenage age. But they still do. I have my 21. I got a phone call an hour ago from my insurance company. They said, we have a claim about the state of New York from your daughter who spun out and hit a 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. Give me a break. That's not going to happen until you match with a 20-year-old's insurance. But anyhow. Okay, there you hear. Let's see what else. That's basically it. I've taught at Cedarbrook University for 27 years. I taught as a nursing there for my 27th year. And I stick with, I'm sticking them out. I stick with one town, one job, one wife. You know, I just sort of stick with it. I don't like change. I do not. If I could have gotten rid of the kids, I would have. I haven't stuck with them, too, forever. No, I haven't. But that's where I am at. Okay? So, you go around the room. You got to tell them your name and something that nobody else knows about. No, we're not doing that. There is my call. Oh, thank you. There's safe places to do that. You know, go around the room, introduce yourself, stuff like that. We're not doing that. Okay? Forget it. Okay. But the goal is here. While we're together, I have three objectives. 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, boy, I learned something. 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 know for this board. 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 one 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 them. Well, that assumes you know it. And you can't apply what you don't know. So, a lot of good it does to 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 should know. They've forgotten some stuff. So, we're going to try to spiff 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, I mean, now everybody else will be able to do it. But they will not. For some inexplicable reason, it's beyond their capabilities. And yeah, I got through school. Yeah, and I got through that. But when I go to the board, it's just going to get me. Those standardized tests are just going to get me. And you don't want to go. Okay? 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 scenario is you go to board, 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 at the board, 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, did 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. When you walk out of here on Sunday, I want you to think, you know, I know how to do those select all and apply. I know how to do those click and drag. 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 in all of those. So, we'll be talking about that. I really believe that any review... There are two types of reviews out there. If you've had reviews, you know this. If some reviews just sit there and they give you a book that's an outline, 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'd probably just leave, figuring I can read it at home. I need somebody to read it to me. And then the other kind of review is, like I said before, they have 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 retentive over here says, it's me. You know, and then all of a sudden, now you guys, your thought process is contaminated because she shouted out the answer. And now, you know what I'm 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 then it takes up 20 minutes arguing about some stupid question. And you're going, oh, let me out of here, you know. This is ridiculous. What's that? That's our class. Okay. So, it just... To me, that doesn't... Neither 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 it, 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 a group this 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 size group, which is great. I like this size. That way I can keep in contact with you. Now, I can't really see your eyes very well. Now, I would like to make some eye contact every 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 could 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. Anything else I need to say? We'll take breaks. 20 minutes. 10 minute breaks. 20 minutes. 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 I always... 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. That's what I'm saying, most likely. So, you do have control of some of our finish 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 3.30 to 9.30? Did you plan a meal? Who planned a meal in there? Who figured we'd just go straight? So, how many figured there was a meal? Like four, three or four of you? Usually, on the first day, we don't do a meal. We just go 10 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 don't allow that food in here. They're not going to cram about it, I would think. Will they cram about it? I would think so. You can do that. Just don't squirt ketchup on your neighbors. Whoops, 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, it depends on, sometimes it's a half hour, sometimes it's an hour. It just depends on where we are and accessibility of food. For those of you guys that are from this area, Mount Carmel and whatnot, what would you say is a reasonably prudent amount of time for a group this size to get lunch and to be reasonable to expect them to be back? What's that? We'll start with 45 minutes tomorrow and we'll see how it works. Alrighty? Okay, I'll plan for that. And then what we'll do is, if everybody's sitting around doing nothing, well, we'll start early. That will mean we'll get out 15 minutes earlier than we would have otherwise. There's a question back here. When's the next time you're offering a review? 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 five to ten minutes south of the airport or five minutes across the street from Turfway Park. If you've ever been down to play the horses down in Cincinnati. But it's on 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 a review first week of March. But none of those, those are all Columbus areas. I also might put in a date to review second or third week of March. It just depends on how those all come together. So, I can't. The website's the best way to look at it. Has everybody been to the website? And that way, as soon as we know something's set, we'll put it on there. So, that's all I can tell you. I don't know otherwise. Then it will be a lot in May. A lot in May. Any other questions? Chamberlain's works is basically like fill-in-the-blank. You have your yellow book, and that's what we're going to do together. The blue book is because people for years and years said to me, what do I do now? What do I do now? Review's 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 board? 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 and parcel of the review. If you haven't done the review book, you have not done Mark Clement's 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, I'll sit down with them and see if they know what they're talking about. We'll sit down and start doing some questions. We probably are ten 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, well, I don't know what that is. Let's get out the blue book. Okay, there it is, page 52. What's it say? Oh, okay, well, then it's A. Yeah, it's A. So, get that blue book out. First question, somebody. On occasion, people will take this course. Not commonly, but on occasion, people will take this course and not be successful on their board. That happens. It happens to every review. There's no perfect review. If there were a perfect review, every other review would be out of business. See what I'm saying? The other thing is that, so what I do is if you would not be successful on your board, 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? Okay, then we'll talk. But you've got to know your blue book first. Then we'll talk. So, it's very important. I can't stress that enough. All right. All right, I think I've covered a variety of issues. I can cover some things as we go if I've missed anything. I think most of the logistics are here. I usually lecture for about an hour and a half before I give a break. Is that okay? Your nurses, you should develop the bionic ladder by now. Yes? I guess I was just wondering, how soon more of the data is there going to be? Yes, now. Is there going to be any changes in the data? Five years. Every five years, it changes in content. Every five years in content. Every three years, they review past data and percentages. There are going to be a few changes as of April 1. What's that? Six weeks from today? April 1, there will be a few changes. But with that... It could be very good for you. It could be very good for you. Because the last time, three years... See, every five years, they change content. And they only change 5% every five years. So, if they change the content, it's only going to be 5% of the content. Not the whole content. Do you understand? Everybody thinks that they change everything every five years. Well, that's because they don't know what they're talking about. Telling you that. They change 5% every five years. Okay? So, in April 1, they will change 5% of the content. All right? 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 95% and not the 5%. Okay? The other thing is they change... They reevaluate the past standard every three years. And they're going to evaluate that April 1 as well. And that could 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... Too high of fail rates from schools all over the place. Just saying. Used to be... Used to be Case Western Reserve never had anybody ever fail. People from there are failing. Christophers was a huge high pass rate. They were having bad times. You start saying, lots of schools have traditionally done really, really well. St. Clair Community College in Dayton stayed up pretty well. But a lot were coming down because they had upped 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 big... 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. Let's talk about... That's the big balance. The first lecture. In the first page, you'll notice the table of contents. There's some page numbers. And then a blank out to the left. What that is, is that's for your assessment compulsive 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 a 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 missed two hours of lecturing. Well, if you're keeping your checklist, you'll know what you've missed. And you'll be able to talk to me about it. And I'll tell you how to get that and how we've arranged for you to get that material you missed. So, if you come up to me and say, I missed yesterday morning. What'd I miss? I'm going to go, I don't remember. You know, 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 alphabetical. Which is kind of odd. Because most reviews go by specialty. They'll do all the pharmacology in one day. And then they'll do all med surgery in one day. Then all T's in another day. Then all sites all at once. I don't know about you guys, but if I had a five-hour review on pharmacology, I would be more confused at the end than I was at the beginning. Because you just can't dump it 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 surgery. Then jumping to some sites. Then back to some T's. And then some O's. And then 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 this test? Okay. 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. And they study that way, and they get anxious that way, and it just doesn't work. See, 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-base is, if they give you an arterial blood gas value report, you have to interpret it as metabolic acidosis, metabolic alkalosis, respiratory alkalosis, respiratory alkalosis. So, if they give you lab values, 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 gases. The first thing I suggest you memorize is the rule of the beads. Do you see it there? The rule of the beads. So, what I want you to do is fill in here. It says, if the pH. That fills your first blank in. And as I say, there's only 3,000 to go. So, if the pH and the bicarb. The pH and the bicarb are both in the same direction, then it's metabolic. So, the beads are bicarb, both, bolic. Do you see those? Bicarb, both, bolic. 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 gas with eight values in it. How many do you look at? There's going to be eight values. How many do you look at? Two. Which two? pH and bicarb. That's what the rule says. Just look at the pH, 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 beads and the bicarb are both in the same direction, it's metabolic. Well, what if they're in different directions? Then you only have one other choice, and that's respiratory. Now, where do you get the acidosis and alkalosis from? The pH. Exactly. So, let's look at how this rule would work. Well, first we have to know the normal. What's the normal pH? 7.35, 7.45? 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 to 26. Not every nurse knows that. They'll learn that. 22, 26. I call them the bicarb years. When you're 22 to 26 years old 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? You know, all those decisions you've got to make when you're 22 to 26. That gives you heartburn. So, you need the bicarb. I call it the bicarb years because you're always in a knot over decisions. It's nice to be 56. No choice here. No other woman wants you. No job wants you. It's nice. You've only got one option. That's 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 to 26. 2, 2, 2, 6. Oh, that's a lot of 6s. A lot of 2s. So, 2, 2, 2, 2, 6. Now, let's look at those and let's look at our example. In the first example, the pH is in what 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. The bicarb. And the bicarb in this case is in what direction? Down. Down. So, draw a little arrow down. Are those arrows going in the same direction? Yes. So, what adjunct must you use? Metabolic. Metabolic. And because the pH is down, it is? Acid. So, that is an example of? Metabolic. Metabolic acid. Okay, look at letter D. Bicarb is in, I mean, the pH is in what direction? Up. Up. Bicarb. Up. Are they both in the same direction? Yes. Yes. So, what adjunct must you use? Metabolic. Metabolic. So, this is metabolic? Alkalosis. Alkalosis. Wait. Is everybody with me? Mm-hmm. Okay, the next one, pH is? Down. Down. Bicarb is? Up. Up. Are they both in the same direction? No. No. So, what adjunct can you not use? Metabolic. Metabolic. So, you have to use? Respiratory. Respiratory. So, this would be respiratory acid. Now, the only time this doesn't work is when there's a mixed acid-base disorder and BORS doesn't go there, because that's way too hard. All right? So, it's pH, does everybody see how the rule works? What if I gave you a bicarb pH, pH of 7.50 and a bicarb of 25? 7.50 and 25, what would it be? Respiratory alkalosis. Respiratory alkalosis, why? Because the pH is too low. The pH is too one direction? No. So, 7.50 would be up. 7.50 is up. And the bicarb is? Down. Normal. 25. It's normal. 25. So, is that the same direction, up and normal? No. So, it's got to be respiratory. So, even if the bicarb is normal, it still works. It's okay. All right. That's the ABG interpretation. Let's talk about signs and symptoms. Letter V. They will ask, they will tell you a patient has respiratory acidosis, metabolic alkalosis, something like that, and they'll tell you, what would you see? Select all that apply. And you get a whole laundry list of stuff, and you have to 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. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. 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I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I do not have you memorizing lists. I want to introduce you to my favorite Scotsman. You know how Scottish surnames have Mac, Dougal, McDonough, MacGyver, MAC, you know. My favorite Scotsman, Matt Kuzma. How many of you have heard of Kuzma? Okay. From now on, I want you, every time you see Kuzma, I want you to think what? Mac Kuzma. In fact, if you're talking to a doctor and you go, he's Mac Kuzma, I'll be happy. It'll make him look stupid, but I'll be happy. The reason is, is Kuzma is a compensatory respiratory pattern for one and only one acid-based disorder. You only see Kuzma with one of the four metabolic disorders, one of the four acid-based disorders. Which one? Well, Mac tells you that. M for what? Metabolism. And AC for? Metabolism. Metabolism. So, Mac Kuzma tells you that you see Kuzma with metabolic acidosis. Acidosis. Okay, we have some knowledge, but we have to be able to what? Apply it. Remember, you can't apply what you do not know. No, but what you know you have to be able to apply. This says, your patient has respiratory acidosis. Select all their thoughts. Thoughts 1, 3, 4, 5. Diarrhea. A-dynamic. Ilias. Spasm. Urinary retention. Paroxysmal. Atrial. Tachycardia. Second degree. Moby. Type 2. Heart block. And hypotalia. I want you guys to get in groups of 2 and 3. Right where you're sitting. You don't have to move. I want you to talk to somebody. Your buddy. And I want you to answer this question. And I want you to use the rule that I taught you. The rule is what? As the D&H goes, so does my patient, except for the tasking. 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 say any answers out loud. Alright. We're choosing which one. We're choosing which one. It means select all and apply. So, we're choosing what is the first one after this. Alright, so. Knowing that as the D&H goes, so does my patient. It goes down, so does the tasking. I'm wondering that. Plus one reflexes. Plus one reflexes would be down, so it would be that. Adding non-amicility. That would be a high. So, that would end up doing it. I co-calibrate. Wait a minute, now that's different, so. Dynamic or not. Except for potassium. So, if it goes down, it means the potassium's up, so. So, I guess it would be down, low is down. So, it would probably be that. Okay, on the way there. Count the number of things selected. Don't say it yet, but I'll ask you for it later on. Count the number of things selected. Is it three plus one? Yeah. Down is zero to one. Zero to one. Zero to one, so that is six to three. Is it two, which is normal? Two's normal. Okay, how many did you select? Three. How many did you select? Three. You should have selected four. So, let's play our game. What did you automatically notice about these questions? You said what? Four. And after those, it's in what direction? Down. And everything's going to go in the same direction, which is what direction? Down. Except for potassium, which is going to go up, so a high K. Okay, so now there's your answer. Now, up or down? Down. Select or no select? Select. Yes. Up or down? Up. Select or no select? Select. No, adynamic, without movement. Down. Up or down? Down. Down. Select or no select? Select. Select. Spasm, up or down? Spasm. Select or no select? Spasm. Urinary retention? Down. Down. Down. Select. Parasympathetic or tachycardia? Select or no? No. Slow or too hard blocked? Yes or no? Yes. Why? Blocked. Blocked means the impulse is being what? Slow. Slow. Blocked. It's down. It's being hindered. So, that's a select. Hypokalemia? No. I'm on a high K, not a low K. So, the answer is the plus one reflects the adynamic illness, the urinary retention, and the second degree of mobility type 2 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 of mobility type 2 hard block? Right? Yes. Yes. And they're testing what principles? What principles are they testing? In an acidotic environment, chemical reactions cease. So, everything shuts down, and that's why you knew it. See? You weren't supposed to have memorized these. You see what my point is? So, this should kind of free you from the fear of the select all that apply. Oh, by the way, what's the number one mistake that people make with select all that apply? Most common mistake made with select all that 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 what. Okay? 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 that apply, 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 that apply. You know, could be, don't go there with select all that apply. That is not cool. Because you're heading down a road that's going to get you wrong. If you do not know that it applies, do not answer select all that... You know what I'm saying? If you don't know that... If you don't know that this is true, then don't pick it. Is that what you said? All right. The other thing about select all that apply, it's never only one and it's never all of them. You know what I'm saying? Never answer just one on a select all that apply and don't answer all of them on a select all that apply. It's never one and it's never all of them. Okay. Let's go to the next page. Causes of acid base disorder. 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 they're flipping it around? Instead of saying, what signs and symptoms will the acid base balance cause, they're asking, what will cause the acid base to balance? And one thing that people do wrong when they answer these kinds of questions is they get signs and symptoms and causation messed up. Do you realize that in the human body, oftentimes what causes something is the opposite of what the signs and symptoms of that thing are? Does everybody understand what I'm saying? So a lot of times what will happen is diarrhea will cause a metabolic acidosis. But once you get acidotic, it will shut your bowels down and you will get a paralytic ileus. Do you see what diarrhea caused this paralytic ileus result from? 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 are you messing up? Causation versus signs and symptoms. So make sure that you... Many times if you go back and you do questions now and you get confused, think, wait a minute, wait a minute, are they talking about signs and symptoms or are they talking about causation? Then you can go, oh, I see where the problem is. Does everybody 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 place. 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? Respiratory. 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 acid. Those are some respiratory acids, correct? Right. Well, how do you tell between those? Well, the second question you ask yourself is, is the client overventilating or underventilating? Is the client or patient overventilating or underventilating? That is going to be critical for your respiratory. If the patient is overventilating, pick alkalosis. If they are underventilating, pick acidosis. Now, this is extremely simple. It's almost methodically 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 alkalosis, right? So, you're choosing between these four words, correct? Well, let's look to see how this works. If the client is overventilating, let's take the 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? Alkalosis. Why alkalosis? Because it's over the normal. So, that's alkalosis. So, if you put them together, ventilating over becomes respiratory alkalosis. See how easy that is? And if I say the patient is underventilating, what does that become? Respiratory. What does under become? Acid. Because that's under the normal. So, under that becomes respiratory acidosis. You see, you're just translating. You're just translating. See that? I just don't know what I'm saying. Do you see how easy this is? You're simply translating. So, when they say overventilating, you say, oh, respiratory alkalosis. Underventilating, respiratory acidosis. So, let me ask you this. They give you a scenario where a woman is overzealously using her breathing techniques during labor. She's really overzealously using those breathing techniques. What acidic disorder would she exhibit? Well, is that lung? Yes. Breathing techniques. Overzealously using breathing. So, that's lung. Is she overventilating or underventilating? Overventilating. Overventilating. 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 acidic disorder would it be? Well, is that a lung scenario? Near drowning. Yes. Would the kid have been overventilating or underventilating when he was near drowning? Under, so he would have respiratory acidosis. Your patient has emphysema and air trapping. Is that lung? Yes. Is he overventilating or underventilating? Under. Under, so he would have respiratory acidosis. Be careful. Ventilating doesn't mean respiratory rate. The respiratory rate is irrelevant here. Everybody pays way too much importance to the respiratory rate. You understand that ventilation has to do with gas exchange, not respiratory rate. For example, I could say that a person had pneumonia in five lobes of their lungs, four lobes of the lungs. Pneumonia in four lobes. They're breathing at 50 a minute, and their SAO2 is 78 on eight liters per mass. You got it? What do they have? Pneumonia in four lobes. They're breathing really fast, but their SAO2 is really low. Now, is that person overventilating or underventilating? Under. 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 don't understand why, because you're paying attention to the wrong piece of information. It's not about the rate. It's about the SAO2. Do 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 underventilating? So, the rate can be tricky. So, what am I trying to tell you? When you get asked a basic disorder question, what piece of data in the question is real shaky to use to get your answer? Respiratory rate, because a lot of times it compensates, which means does the opposite, so you'll totally get the wrong answer. You see what I'm saying? Pay attention to what? SAO2. If somebody's on a PCA pump, what acid-base imbalance would tell you that maybe they need to come off that thing? If they're on a PCA pump, what acid-base disorder would tell you they need to maybe come off that thing? Well, you say, okay, well, PCA pump, what do we know about PCA pumps? Say what? Depressed respirations. Why would they need to come off of it if they were, what, getting too much, which would make my respiratory rate go really, what, my ventilations go really down, which would mean I would be underventilating. So, the answer would be respiratory acidosis. So, respiratory acidosis would tell you that maybe you need to back off that PCA pump. Does everything make sense? You 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. So, this is a what? A tool. So, use the tools at your disposal. Don't say, I can't get the screw out and the screwdriver's still sitting in the box. Now, 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 leave the tools in the box. You know what I'm saying? Get the tools out. Start using them. What if it's not lung? The next box says, what if it isn't lung? Then it's metabolic. If it isn't lung, it's metabolic. Well, good news. There's really only one scenario where you will answer metabolic alkalosis, and that's what the next fill-in-the-blanks says. It says, if the patient has prolonged gastric vomiting or suctioning sick metabolic alkalosis. Why? Why does prolonged gastric vomiting and suctioning lead to metabolic alkalosis? You're losing acid. You lose acid. You become vacant. Otherwise, everything else that isn't lung, you pick metabolic acidosis. For everything else that isn't lung, that's another fill-in-the-blanks. For everything else that is not lung, pick metabolic acidosis. So let me ask you this. Let me ask you this. A patient has GI surgery. He has had a NG tube to low intermittent gong code suctioning for three days. What acid-base disorder would he most likely exhibit? Metabolic alkalosis. Metabolic alkalosis. If your patient has hyperemesis gravidarum, what acid-base disorder are they most likely to exhibit? Metabolic alkalosis. Metabolic alkalosis. If your patient with hyperemesis gravidarum is now dehydrated, what acid-base disorder would they have? Now they've got some dehydration. That's not prolonged gastric vomiting or suctioning. It's something you see with it, but it isn't what it is. So now what would they have? Metabolic acidosis. Yeah, it flips on the other side and now you're there. Good point. What about this? A person has acute renal failure. What acid-base disorder? Acute renal failure. What acid-base disorder? Why metabolic acidosis? Why? You're right, but why? Is it lung? No. Is it vomiting or suctioning? No. So it's got to be metabolic acidosis because everything that isn't lung or vomiting or suctioning is metabolic acidosis. So what about infantile diarrhea? What acid-base disorder? Metabolic acidosis. Why? It's not lung and it's not vomiting. That's the other end. Diarrhea. Okay. What about third-degree burns to over 60% of the body? Third-degree burns to over 60% of the body, first phase. What? Absolutely, metabolic acidosis because it's not what? Lung. It's lung and it's not vomiting or suctioning. Okay, what acid-base disorder do you see with idiopathic bulimic perfidus? What? What? Yeah, metabolic acidosis. Very good. Why? Why? I mean, I don't know what it is. It is lung, though. But it is lung. I mean, it's only, you've got one body system out of 13. Right? And if it's vomiting or suctioning, you've got one out of a thousand systems. So when you don't know what it is, what's your answer? Absolutely, metabolic acidosis. Everybody, right now. Right now, as you're sitting there, I want you to set your default setting for answering acid-base questions to metabolic acidosis. Okay, everybody, do it. Okay? Do it. Do it. So that 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. It's what? I've used that rule for 20 years. I take the FD twice a year. I take ATIs. I take Kaplan... No, stop. Kaplan quality materials. And 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 mean, I better know what's out there, and I better know what's current, and I better know how it's being tested. So I've done... 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... And every time I don't know, on an acid-base question, what does Mark Fleming say? And he's 100% right every time. I have never missed a question using that. All right? All right. So let me ask you this. 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. Has the pH dose of my patient except for potassium? MAC too small? Overventilate? Underventilate? Translate? Vomiting or suction? Metabolic alkalosis? Everything else, metabolic acidosis. If I don't know what to take, metabolic acidosis. That's acid-base. That's all you have to know. So, say it with me. If the... If the pH and the bicarb are both in the same direction, it's metabolic. As the pH goes, so does my patient except for potassium. Who's your favorite specimen? MAC too small? Okay. Overventilate? Underventilate? Translate? What do I mean by that? Overventilate? Underventilate? Translate? Yeah, translate's all right. Overventilated? Respiratory alkalosis? Respiratory... Underventilated? Respiratory acidosis? If it's vomiting or suctioning, take? Metabolic alkalosis? For everything else, take? Metabolic acidosis. And when you don't know what to take, take? Metabolic acidosis. Yeah, I use that all the time. Those... That works for you. Okay, those are helpful tools that work. All right, yes? This one, just to make this clear, that one question you asked, if you have severe vomiting and you've gotten dehydrated now, if you look at the dehydration... Dehydration, right. So now it's... Right, there's a rule in test taking. So watch what they're asking. Yeah. When you want to get a question right, you always pay more attention to the modifying phrase than the original noun. Everybody hear that? You always pay more attention to the modifying phrase than the original noun. See what I'm saying? So a person with obsessive-compulsive disorder who is now psychotic, what's more important, psychotic than obsessive? See what I'm saying? A patient with vomiting who is now dehydrated. The dehydrated takes precedence over. So the modifying phrase trumps original noun. And people get caught on that error three times. Error three times. Both in questions. They crash and burn on that. Because they're focusing on original noun. It's gone past original noun. So it's now modifying phrase is what the question's on. Good question. Okay, let's talk about ventilation. We'll take a break. Ventilators. The first two things you have to know is the alarm. You have to know the alarm system. And you have to know how the blood gases articulate with ventilation. There is 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 a vent, 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 it that. And then when it exceeds that, the high-pressure alarm goes off. Say if you set the high-pressure at 40 millimeters of mercury. And you say, I don't want you to push. 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, obstruction. There are three obstructions. Number one, kinks in the tubing. The tubing can do kinks. Would that increase resistance? Sure. So, what do you do for that? That's rocket science. Un-kink. Okay. Then, second most common obstruction is water condensing within the tube. There's water condensing in the dependent loops. So, what do you do for that? Now, there are more rocket science here. Empty it. And the third most common cause is mucus secretions in the airway. They've got goop there. Milk. Junk. Mucus. And what do you do for that? Suction. Now, what will be suction is correct, but what would you do before you suction? And I'm not talking about pre-oxygenating it, because that is true, but is there another strategy that would be done to mobilize secretions before you would actually suction? What would you do? Yeah. Change position. Turn top degree. Change position. Turn top degree. So, you would do that first, and if that didn't work, what would you do? Suction. 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 and problems you cause. So, it's a double-edged sword. So, how often do you suction patients? Every 16 minutes, every hour, every two hours, every four hours, or none of the above? None of the above. How often do you suction people? As necessary, and that means when they cannot mobilize it after they've been turned and coughed and deep breathed. In the ICU, I'm notorious for getting... Nurses always negatively talk about me in ICU, because I don't do much suctioning. So, I do an awful lot of turning. And I find if somebody's O2 stat's 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. The patient coughs, and whack, and out comes this thing, hits the wall on the other side. And then they pick up, and they're just fine. Thank you. And I never did suctioning. And I'll go in and report, and they'll say, how many times did you suction them? I didn't suction them at all. How come you never suctioned people? Well, his O2 stat is 98 on room air. You got a problem with this? Because his lungs are clear. He's got 98 on room air. Temperature's normal. You got a problem? Okay. So, I do a lot of turning then. I do a lot of turning and coughing and deep breathing. I find I don't 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 off. What do you do first? What do you click first? Un-kink. Check for kinks and un-kink. 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 breathe. Click, drag, drop. Then what? Suction. Click, drag, drop. That would be your order. Turn the page and let's talk about low-pressure alarms. What's this say? Decrease resistance. Remember I told you you always set a low level? And if it's below that, there's decreased resistance? So, what's the machine say? That was too easy, yeah. I had to work too little. That was way too easy, pushing that breath in. Well, what do you think would cause a low-pressure alarm? Decreased resistance. Disconnection. 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's the oxygen sensor tubing? What is that? Anybody know? It senses the FiO2 right at the airway area. What's it look like? Anybody know what it is? It comes from the ventilator machine. It's a wiring, black coated wire. It's very small. It's probably about half the diameter of your pencil or pen that you're using there. And it goes right along the tubing, piggybacking it along the tubing, and it comes right where the trach or the endotube is, and it kind of just hooks. It's like a... Do you have a computer where you, when your battery's low, you take the cord and you hook that little cord in there, makes a right angle. Do you have one like that? Well, it's like that. It hooks into that hole in the tubing, and it measures the FiO2, the oxygen delivered right there. But if that pops off, when the air comes in, what's it do? It goes out that tube instead of into them, and there's less resistance. Do you see how that would work? So you have to just take that sensor and plug it back in. Because so many nurses, they would be going bong, bong, bong, low pressure, and 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. In general, what are low-pressure alarms due to? Disconnections. LPNs, this is the same as RNs. Do you understand? The RNs test the LPNs. It's the same information. It's just from a different perspective. For example, like an 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. Do you see what I'm saying? LPNs and RNs need to know basically the same kinds of things. They just need to know the difference in the scope of their practice. In some ways, no, I won't go there. Okay. What about acid-base disorders? Respiratory alkalosis. Respiratory alkalosis means the ventilator settings may be too what? Why did you say that? We can turn respiratory alkalosis into another word. What can we turn it into? Respiratory. Ventilating. Alkalosis. Over. Over. So then you're right. Overventilating means the ventilator settings may be too, see how easy it is? All you do is take these acid-base disorders, turn them into just normal words, and the answer will jump off the page after. So what is the other word for respiratory acidosis? Underventilating. Underventilating. So underventilating means the settings are too low. Do you got that? Now how would this be applied in a question? And this will do the question, then go to our break. The doctor says wean off vent in AM. Got it? He's writing it today for tomorrow. Wean the patient off the ventilator in the morning tomorrow. The 6 AM ABD 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 second. What would you do? Talk to your buddy. The answer would be wherever it says call doctor, you can put notify RN. What's your answer? The answer is C. Why did you go with C? He's underventilating. How do you know he's underventilating? Does he need his ventilator? Oh yeah, he does. He's being underventilated on the ventilator. He's on the ventilator and he's already underventilated on the ventilator. Am I going to take him off the ventilator? It's going to be even worse. So what acid-base disorder did you want to see at 6 AM? Respiratory alkalosis, which means he's being overventilated and in that case he probably doesn't need the ventilator. So is this hard to read? An hour ago, I told you you've got to get a bunch of questions on ventilators and acid-base and how do you use your acid-base and balances to know what to do with ventilators. How many of you keep going, oh my goodness. How many of you see it's not really hard, it's very simple. These would be windbags. Why is D a bad answer? Why is D a bad answer? What's that? Yeah, never pick an answer where you don't do something and somebody else has to do something. At the same time, 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 afraid to call if you have respiratory therapy. If a 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 not pick call 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? You sure that's the answer? It's not the answer. Yeah, you're going to hell. How's it make you feel? Don't tell anybody I said that. Okay, let's take a ten minute break. You guys have been really good. We'll come back at 25 after. Okay. This gentleman. If you're going to give a call to a nurse, you're going to be required to give your call to a nurse. Give it back. Give it back. You're going to have to remember this gentleman. Give it back to him. Give it back to him. Give it back to him. Give it back to him. Give it back to him. Give it back to him. Give it back to him. Give it back to him. Give it back to him. Give it back to him. Give it back to him. Give it back to him. Give it back to him. Give it back to him. Give it back to him. Give it back to him. Give it back to him. Give it back to him. Give it back to him. Give it back to him. Give it back to him. Give it back to him. Give it back to him. Give it back to him. Give it back to him. Give it back to him. Give it back to him. Give it back to him. Give it back to him. Give it back to him. Give it back to him. Give it back to him. Give it back to him. Give it back to him. Give it back to him. Give it back to him. Give it back to him. Give it back to him. Give it back to him. 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