Online tutoring session recording 7-26-19 Study tips, anemias

Online tutoring session recording 7-26-19 Study tips, anemias



can everybody hear me okay okay great all right I'm just gonna take inventory of who is here new Brianna Jessica Rachel and Lourdes okay okay great so let's go ahead and get started what kind of questions do you guys have this week you you you so you're lost on how to study there's a lot of information yeah I understand that there is a lot of information that's why I try to categorize as much as possible it's very important because otherwise your brain gets just lost in all of the details if you can categorize and like that's why I said organization is so important because if you can organize your material then you can take that material and sit it side-by-side with your other material and you can start to compare and contrast and be like oh we could all have the anemias all of the anemias have very similar diets except you know this one has dairy in it but they all have nuts and beans and seeds and green leafy vegetables so it's nice to be able to make those categories so that your brain doesn't give it overwhelmed with all the information and I think that's probably the best thing is to try to make sense of things categorize things understand things as much as possible you know like when you're talking about a post-op like recovery room what you should be looking for and what are the you know the nursing considerations in the recovery room and you know you can really can just narrow it down to your watching for the patient's breathing status to be stable you're watching for their circulatory status to be stable so you're watching for that blood pressure and heart rate to be careful that they're not bleeding or dehydrated and then you also are watching their temperature because you're watching for hypothermia or hyperthermia but more hypothermia so you know just trying to categorize things instead of trying to memorize every little detail and then Lourdes says can you talk about acid-base balance post-op so I think what you're thinking of is because you guys haven't gotten to acid-base balance too much yet but I do know that they do mention respiratory acidosis as a major consideration post-op because of the effects of anesthesia so remember that anesthesia when you're given general anesthesia for surgery it's like a CNS depressant it knocks you out you're unconscious and so they you know they put you on a ventilator to protect your airway and then when you get into the post-op period like in the recovery room they'll take them they'll take the breathing tube out and you have to breathe on your own again so the nurse has to watch these patients to make sure that their breathing gets deeper and faster remember we because the anesthesia will make breathing shallow and slower so we want to make sure that they're taking nice big deep breaths and that they are maintaining an o2 set and adequate oxygen saturation and that they are breathing between 12 to 20 breaths per minute so we're watching all of those things because if they don't you have to remember that you're going to breathe in oxygen and breathe out co2 so if your respiratory rate is too slow or your respiratory depth is too shallow then you can't rid your body of the co2 like you should and co2 is an acid so that would be a respiratory acidosis did that help Lourdes okay good does anybody have any other questions or any topics that you want to talk about you how are they anemias doing with you guys are you guys understanding the anemias okay cuz I know we haven't talked about those yet valsalva so the valsalva maneuver is when you tell somebody to bear down when you bear down like i always tell a woman you know an older woman i'll be like bear down like you're pushing a baby out or you can tell them to bear down like they're having a bowel movement and what that does is that simulates the parasympathetic nervous system so it will slow down a heart rate it will also teach the patient to hold their breath so like if you tell them to bear down they're not going to breathe when they're bearing down so I think for you guys what you're talking about for the valsalva maneuver is gonna be um when you are taking out a central line so when you're taking out a central line you always want to make sure and that can be a regular triple lumen central line or it can be a peripherally inserted central catheter or a PICC line when you're pulling those out you have to make sure that the patient isn't breathing you want them to hold their breath while they're doing that the best way for them to do that is to bear down or valsalva maneuver the reason you don't want them to breathe is because you don't want any pressure changes in the thoracic cavity while you're pulling that line out of their neck or out of their arm because those changes in the the pressure changes in the thoracic cavity can pull air into the blood vessel and that can cause what they call an air embolism and the air embolism can travel to the brain and act like a stroke so that's why we always tell them to bear down when we're pulling the central line out does that make sense okay great so let's go over the anemias end so we have four major anemias that we're focusing on the first one is like in a class by himself and that's the sickle cell anemia let me go ahead and pull up my screen for you guys so you guys can see it's you don't have to sit here and look at me all day hold on here just a second can you guys see that or do you see what do you see do you see the screen the anemia screen let's see here you hold on a sec I'm having technical difficulties just a second you there it is it was like way in the back okay yes okay hold on just a second let me try to pull the screen back up here you some reason I'm not seeing the chat here it is nevermind I fixed it yay ok sorry about that I was having trouble finding the chat box you guys were talking to me and I couldn't see it okay so now I can see the screen that I'm referring to and I can see what you guys are saying so this is good okay so Florida's these slits are my slides from the lecture that I teach for 170 which is the two-year equivalent to 242 so these are just ones that I have for me from for the class that I teach but I just use them when I'm talking to you guys so that I can umm so that you can have something to refer to when I'm talking to you um so let's talk about sickle cell anemia first let's see here so sickle cell is pretty serious I mean it can be very serious for people it has a lot of negative effects that can happen to people that have it but basically what happens is the cells have a hemoglobin on them called hemoglobin s usually they have hemoglobin a now we have hemoglobin s and that hemoglobin s doesn't like hypoxia so when those cells are exposed to hypoxia they sickle and they get sticky so what happens is they sickles oh they can't carry oxygen and they get sticky which means they're gonna stick together and clog vessels they can clog blood vessels and I know miss ala referred to that as a vaso occlusive event that's what she's talking about where the cells you get a whole bunch of cells that starts tickling together enough to clog a blood vessel that's called a vaso occlusive event so what are some of the things that can cause sickling and the best way to think about if the cells don't like hypoxia then the best thing to think is that hypoxia is going to cause tickling so anything that's going to increase oxygen demand from the body or decreases oxygen supply to the body is going to cause this so for example dehydration and in an infection are going to increase oxygen demand right because the body is going to need more oxygen to fight off infection and function under dehydration emotional stress that straight triggers the fight-or-flight that's going to increase your metabolism and going to require more oxygen pregnancy obviously we know the oxygen demand goes up their altitude changes that decreases oxygen supply because remember the air has less concentration of oxygen the higher up you get cold weather so cold weather is going to vasoconstrict and therefore cause and high pox anesthesia we know can be stressful to the body so that's going to cause increased demand and then strenuous exercise can also cause increased demand so basically anything that's going to put stress on the body can cause a crisis to happen so if you think about this this is an endless cycle that goes on the cells sickle because of hypoxia but then they can't carry oxygen and they black blood vessels which furthers hypoxia so then more cells sickle so it's a it's a snowball effect so what's the best thing to do for these guys well we want to give them oxygen that's the best thing we can do for them is to try to give them oxygen there's other things too what we'll talk about those in a second so we have symptoms of sickle cell anemia look at these so here's where categorization can take place we talked about categorizing the causes of sickle cell how they all have to do with decreased oxygenation so the symptoms of sickle cell also all have to do with decrease oxygenation all of them either decrease oxygenation or decreased perfusion so pain pallor lower extremity ulcers chronic kidney disease cardiovascular issues musculoskeletal those all have to do with either the not getting enough oxygen to the tissues or not getting enough blood to the tissues which results is not enough oxygen except for jaundice jaundice is the one where you have these cells that have the hemoglobin s they don't live as long as the ones that have hemoglobin a so these disease cells that have hemoglobin s only live 10 to 20 days whereas the cells with hemoglobin a they live 120 days so because they live in much shorter life they break apart more often and a byproduct of red cell breakdown is bilirubin so in bilirubin builds up in the bloodstream and in this it's gonna leak out into the skin that's where the jaundice comes from and again that happens because you have more red cells dying more often because they don't live as long as a normal red cell does so you're having you're gonna have a chance of building high bilirubin and jaundice that's also where the unny me a part of sickle cell anemia from is because you have these red cells that are dying more frequently so you get an anemic effect and mm-hmm let's see here and then the treatment of sickle cell is just obviously we're gonna give them oxygen because oxygen if the problem is hypoxia then give them oxygen to try to stop that endless cycle from happening also give them pain meds so pain meds are really important because they're going to be in a lot of pain like we know that that's the number one cause or not cause the number one symptom of sickle cell is pain so if they have a lot of pain there that fight or flight is going to kick in and their oxygen demand is going to go up drastically so we want to give them pain medication to get that pain under control that's very important as well and then IV fluids and drinking as well drinking beverages no caffeine though because caffeine is gonna increase metabolism and going to it's a stimulant so we don't want stimulants because those increase oxygen demand and we want to do hypotonic IV fluids because the sick old cells need rehydration so we rehydrate them with hypotonic remember because hypotonic fluids will pull fluid into the cell so we want hypotonic so there's a little acronym that you can think of for this one it's called hop to it so hop hydration oxygenation and pain control those are your top three interventions for sickle cell crisis hydrate with hypotonic oxygenation and pain control hop hop to it and then the rest of these all have to do with decreasing anything that's going to cause vasoconstriction or compression so pretty much the rest of these have to do with decreasing vasoconstriction or compression so blood pressure cuff sequential compression devices restrictive clothing keeping the room temp warm if you keep it cold good they're gonna vasoconstrict so you'll want to keep it warm for them give me a cold is going to increase their pain so that pretty much is sickle-cell any other question any questions on sickle cell I know I've been yapping along here I want to make sure nobody has any questions you no I must be doing a good job then okay so the rest of these anemias you can kind of lump together into into one category because they're all gonna have anemia type symptoms but then these symptoms here these are all signs and symptoms of decreased perfusion or decreased oxygenation again but then you also have the symptoms that are specific to each anaemia so you can say every anaemia is gonna have these symptoms but then each of these other anemias have other symptoms that are associated just with that anaemia like iron deficiency just has the spooning nails right and can anyone tell me what b12 what's special about b12 the symptoms of b12 deficiency you are you all sleeping out there is the rain putting everybody to sleep what is special about the symptoms of b12 deficiency that no other anaemia has this Oh Rachel you're looking it up Lourdes all of the anemias are gonna have pallor sickle-cell a jaundice is gonna be a special for sickle-cell the actual answer I was looking for is neurological symptoms neurological symptoms b12 is specific for neurological symptoms and the reason why is because we twelve is responsible for maintaining the myelin sheath so if anybody if you guys remember what the myelin sheath is back from your days at A&P the myelin sheath is kind of like the insulation on our nerves they help nerve signals travel fast and efficiently so if the b12 is not there to maintain the myelin sheath the myelin sheath can start to break down and then you get you get unreliable signals and that's where the numbness and tingling around the mouth comes from that's where the anxiety depression memory issues all of those things come from because of the myelin sheath not being maintained correctly so that's why we have to remember about b12 now they do have that they call it let me see I have a picture of it here I'll show you that has to do with their tongue that you guys are talking about it's like a beefy red looking tongue here that glossitis the b12 has that from what I've read somebody asked me if folic acid deficiency has that too and I can't remember if they said that it does or not I can't remember I want to say that it does that folic acid deficiency can also have the glossitis but I can't remember I do know that b12 though the neuro symptoms are exclusive to b12 deficiency you and then we also have to remember that you need both b12 and folate together in the body so you need them both in order to not have an anemia so the reason for this is because b12 and folate come together they kind of join together they join forces and they mature all the baby red cells that are coming from the bone marrow so if B twelves not there then it can't join with folate to mature the baby cells so the b12 and folate have to go arm and arm together to the baby red cell to mature it if neither one if one is missing then they can't mature the red cell so that's why you can get a folic acid deficiency anemia or b12 deficiency anemia but the b12 has the neuro symptoms because b12 itself is also responsible for myelin sheath maintenance it's not just responsible for maturing red cells it's also responsible for myelin sheath so that's why you get the neuro symptoms as well with b12 and then if you look at the diets for all of these they're pretty let's see iron has nuts and seeds now what is happening here I'm trying to move things around nuts and seeds beans green leafies and then we've have especially like red beets and organ meats but look at the other ones here here's b12 nuts and seeds again beans and green leafies again right all this folic acid I'm sorry folic acid is nuts seeds beans and green leafies just like iron but iron also has the red meat and where is b12 here it is nuts dried beans and leafy greens so you can start to see that a lot of the the anemias have similar diets b12 also has dairy and iron I believe also has like the organ meats so it's good to try to get all of these and line them up and compare them and say okay they all have this they all have this they all have this this one has this in particular so you can do that with it with the symptoms of the anemias as well they all have these generalized anemia symptoms but iron deficiency gets the spoon nails and they also get that pie Cup where they crave things to eat that aren't usually edible like paint chips or soil or soap some of them just like to chomp on ice that's probably like a safer version of pie cup so you're really not gonna sometimes you can harm your teeth if you chronically chomp on ice but so then b12 has the neuro symptoms and the glossitis and then folic acid they have the anemia symptoms let me see a full I guess it has any of the other symptoms yeah they have similar symptoms to b12 yeah except for the neuro so that's really the anemias and the best way to treat the anemias is to give them whatever they're missing so if they're if they're iron deficient give them iron if they're b12 deficient you can give them b12 they're folic acid deficient give them foley so the treatments are nice and easy to remember any other questions on the anemias you the anemias are nice because they're all you know they have similar diets the treatments are pretty simple the causes are pretty simple as well they all either have to do with decreased intake or malabsorption pretty much iron deficiency has a couple extra ones but I mean they're pretty straightforward sickle cells a little bit more complicated but even that one because you can categorize it so easily that was pretty pretty straightforward – how are you guys feeling about blood blood products and blood transfusions do you have to know TPN for this test those TPN on your on your syllabus I can't remember yes TPN okay let's talk about CP n um hang on just a second I'm gonna pull up the slide that has that on there let's see here you can you guys see the GI screen or are you guys still seeing the anemia screen this screen share is is not working like okay so what it's showing me is not what it's showing you okay let me share something here okay now you guys should see the GI screen you see it okay good all right let me scroll down to TPN I have TPN at the end here somewhere here it is so this is TP n TP n is basically IV food and you also so the TPN usually comes in a bag like this a very big bag it usually runs for 24 hours and it has basically everything you need to survive and this is usually used for people who can't eat they can't use their GI tract so even if somebody just has like a mouth problem the doctor will sometimes put like a temporary PEG tube in or something like that so that we can still continue to use the GI tract because the GI tract is always the preferred method of receiving nutrition but if for some reason the GI tract is unavailable cannot be used I'll give you some examples if you have a severe gastrointestinal disease that has a really bad flare-up like Crohn's disease sometimes they want to give the GI tract rest for an extended period of time that's when they would use TPN if it's just GI rest for like two or three days they'll probably just keep you NPO and give you IV fluids but if you have to be NPO and the GI tract needs rest for an extended period of time that's when they use TPN I'll giving an example of another example when they would use TPN I took care of a gentleman who was hit by a drunk driver and he had severe abdominal trauma and he had 16 different surgeries to repair his intestines from the car accident so he did not have use of his GI tract for a long period of time I think it was like oh gosh I want to say like three weeks maybe four weeks so they put him on TPN and basically it just keeps you alive but they try to get you off of this as soon as they can because there's a lot of complications to it so but that's basically what it is the TPN is the big bag here and then the lipids are the smaller bag they usually aren't mixed together they're two separate bags and we have fluids in here we have protein carbs lots of glucose in their fat and then we have all your electrolytes and vitamins and minerals so basically the the doctor will order labs every day and so say the patient has TPN running at the doctor's original order the doctor will order labs for the following morning the labs will be drawn so then when the doctor comes in the doctor can say okay tell pharmacy that with a new bag of TPN that gets hung today I want to change the order to this so they look at the patient's labs and they change the order of the TPN meaning maybe the patient needs more protein or maybe we have to back off the glucose a little bit because their sugars running high or maybe their potassium is a little bit lower so they're gonna increase the potassium level so they will adjust the dose of the TPN and what they want in it on a daily basis every single day so you get a new fresh bag from the pharmacy every day for the TPN some major considerations for TPN so you always want to make sure you verify it with two nurses when you're hanging it so when you're hanging a new bag you always have another nurse verify the prescription so you want to make sure that the nurse looks at the doctor's order and the label on the bag from the pharmacy to make sure they match you check it and then another nurse checks it before you hang it up TPS should never be stopped suddenly because what you have to remember is that's a constant flow of sugar into your bloodstream so that's the source of glucose that your body has at that time and it's a constant flow coming in it's not peaks and valleys like it is when you eat when you eat you usually have you know you'll have an influx of glucose once your stomach processes the food and dumps it into the duodenum the duodenum will start absorbing the glucose into the bloodstream and then the pancreas kicks in with the insulin to take care of it to feed it to the cells but when you have TPN going it's a constant river of glucose coming in through the blood into the bloodstream through the vein so what does the pancreas do the pancreas releases a constant flow of insulin to match the glucose that's coming in so now you can imagine if you stop that River suddenly and you have no more glucose coming in the pancreas is still releasing insulin so it's gonna use up whatever glucose is left in the bloodstream and it's gonna drop the blood sugar so that's why if for some reason you run out of TPN or something like that you always make sure that you get 20 or 10 or 20 percent dextrose and hang that because that will keep that river of glucose going so that the patient doesn't become hypoglycemic until you can get your next bag of TPN obviously always on a pump and then we just say you change the tubing when you change the bag so the bag runs for 24 hours you just change the tubing when you change the bag I always change for every 24 hours now we know like unusual IV fluids like normal saline half-normal saline we usually change those every 72 can you want to tell me why you think we would have to change this TPN tubing every 24 so every day instead of every three days well the formula is changing everyday definitely but we could just hang a new bag and leave the tubing there right kind of like we do when we change IV bags out why would we why is it mandatory that we change the tubing every day you yes Briana infection so what's running through that tubing that might increase the patient's risk of infection you what is in that TPN that's going to increase the patient risk of infection you glucose glucose bacteria love sugar okay that's something that you guys should kind of always keep in the back of your mind anytime you're dealing with glucose so like if when you're learning about diabetes but I think that's your next test is diabetes when you're thinking about diabetes or when you're working with TPN glucose glucose glucose so glucose is a form of sugar bacteria love sugar so we have to change to brand-new tubing every 24 hours to make sure that we don't have bacterial growth in that tubing because of the glucose and then it usually goes through a central line and usually we change central line dressings every seven days but any central lines that have TPN going through them have to meet the dressing has to be changed every two to three days so we changed the tubing itself every 24 hours and we change the dressing on the central line every 48 to 72 hours and it's for the same reason because you increase the risk of infection because of the glucose that's going through the blood stream so that's you see white TPN is not something that they prefer to use they prefer to use the GI tract if they can but if they can't then we worry then we give them TPN and we worry about all of these things happening fluid overload so you always have to make sure that the patient is getting weighed every day and ayano's are getting monitored every day always gonna check the BMP every day to make sure the electrolytes are staying in balance checking that glucose every six hours making sure they're not getting too high and then we don't stop the TP and abruptly because they could drop too low and then we're always watching for infection because bacteria love sugar so any questions on TPM you you okay good alright and then you guys said you wanted to talk about the blood products I'll do it I can show you that real quick here you okay so the major blood products that you have to think about are the packed red cells the platelets and the fresh frozen plasma or FFP so packed red blood cells or prbcs they always need to type and cross-match and the FFP or fresh frozen plasma that one also always needs a type and cross-match and then we also have to remember why we give them so packed red cells are given for anemia platelets are given for low platelets or thrombocytopenia and fresh frozen plasma is given to replace blood volume or and replace clotting factor so a good reason why you would see somebody use FFP would be if you have somebody who's going in for emergency surgery and they have an INR of you know two point five the doctor will probably order a unit of FFP to put more clotting factors in the blood so we can bring that clotting time back down to normal because we don't want them to bleed out when they're going into surgery so that would be an example of when you would see them use FFP sometimes I'll use FFP too if like somebody comes in with an elevated INR like too much warfarin they will use the FFP along with vitamin K to help get that INR down faster platelets are usually given they're given through a short set a short transfusion set it's not the Wye tubing that you see with the FFP and the red cells it's a shorter set and it's usually given really fast and it just runs in real quickly a short set and it's given for low platelets don't need to type and cross-match remember platelets are the ones that you can get several donors in one bag so you don't need to type and cross-match them and then we have the lovely blood compatibility chart so you know you have to understand who's the universal recipient who's the universal donor and if you have a certain blood type what can that person receive as a blood transfusion so the best way to think of this is a B and positive are markers oh and negative are not they are not markers they're considered non markers so a B and positive are your markers so if somebody has a blood type that doesn't have a certain marker you can't give them blood with that marker so for example if you have a patient who has a negative blood he can he cannot get any blood that has positive in it and he can cannot get any blood that has B in it because all the only marker he has on his blood is a so he can basically get a negative blood or own egative blood those are two types of blood he can get because remember we said o and negative are non markers so that's why they call a negative the universal donor because it has no markers on it so anybody can get that blood that's the same reason why they call a B+ the universal recipient because a B positive blood has all of the markers so they can receive any blood because they have all the markers so then it's just a matter of going through and practicing okay so if this person has a B negative blood they can receive any blood except a positive right so they could receive a B a B negative blood they can receive a negative blood B negative blood and own negative blood because they can receive any of the letters they just can't receive the positive because they don't have the positive markers so it's just a matter of going through and practicing those and then you know we have the blood transfusion considerations always hang red blood cells with normal saline you always have to give it within 30 minutes of you getting it from the blood bank and you always have to infuse it within 4 hours of getting it from the blood bank and you always start off slow usually at about 50 cc's an hour and you monitor them for the first 15 minutes of the transfusion time so remember if you're putting blood into an IV line that you've primed with normal saline you have to wait for the blood to get to the patient so you've got to let all the Saline get through the line and then the blood to get down to the patient before you start that 15-minute clock so it's 15 minutes from when the blood hits the patient we usually want to use a 20 gauge or higher so that we make sure that the blood gets in there efficiently and we also want to make sure that we check with two nurses and we also would not only monitor for a blood transfusion reaction but we also make sure we monitor for fluid volume overload so especially any elderly person cardiac or renal issues you always want to watch and do a lung assessment prior to starting a transfusion cause you always want to make sure that the patient has clear lung sounds before you start and then you can check them you know throughout the transfusion to make sure they're not developing crackles because that's a significant risk for somebody who's getting a blood transfusion especially if they're at risk for fluid volume overload so you guys want to check them and make sure that they're not developing crackles and a lot of times a and I don't know if you guys have seen this in practice or not but when blood transfusions are given especially if it's more than one unit of blood a lot of times the physician will order if you're owesome I'd like in between units or after the units to rid the body of the excess fluid and just keep their red cells so any questions on blood products any other questions or anything you guys want to talk about today how are platelets administered platelets are given through their given IV just like red blood cells and fresh frozen plasma but you don't get the why to Bing you do them fast usually any blood product you usually want to keep them at a 20-gauge or higher but it's infused quickly usually over 15 to 30 minutes and it has a special administration ship set it's much shorter than the blood cell tubing like the rip the packed red blood cell tubing and the FFP tubing is the y set that has the sale that you hook the saline and then the blood product to platelets don't have that platelets just have like a single line it's similar to what a piggyback line would look like it's short like that maybe a little bit longer than a piggyback line but it's not long like the primary lines are you you any other questions do we need a second nurse to verify FFP yes because it has a type and cross-match I would yes mm-hmm actually I'm pretty sure any blood product you usually verify but especially the ones that require type and cross-match yeah that's a definite you'd want to a second as a nurse to verify so I think your exam is next week correct the second or the first so is it oh it's Thursday the first okay okay all right so do you guys have any other questions make sure you guys are doing practice questions definitely get working on those practice questions the ones that I sent out make sure you're doing a few of those every day and really picking them apart I've I've I've had students come to me and you know they're wondering about why they're getting their questions wrong and then I'll point it out Oh see you missed the word older adult or you missed the fact that they're in the recovery room that they aren't 12 hours post-op there two hours post-op so they're still in the recovery room you know so you just have to make sure that you are careful with those key words and the question or if it says what should the nurse do first that usually means it's a nursing process question that means chronologically what would you do first why no blood draws from a midline I believe the mid lines are shorter and they I don't believe they go they don't go all the way to the right atrium and I can't remember why you don't draw from a midline but I do remember that you don't drop them in I can't remember why I'm sorry Lourdes I do know that they're a lot shorter though then than the central lines um also remember that if it says which is most important which is essential which is priority you have to make sure you're gonna pick an answer that solves the problem so you know you say if there's only one thing that I can do and then I have to leave the room which one of these answers would I choose so that's usually now I say usually sometimes it happens but that's usually why you have you don't pick an assessment answer when it's a priority question usually because assessing doesn't really solve the problem assessing is just watching and waiting for something to happen so and you can always check your answer by saying to yourself okay I've left the room I picked my intervention I've left the room and I'll peek in and say how is he now so if you have a patient who's short of breath and you choose to check his oxygen saturation as your priority then you say that's the only thing I can do for him is check his o2 set and then I have to leave the room how is my patient now well he's still short of breath so that shouldn't be your priority now if the question asks you what would the nurse do first with somebody who's short of breath you'd probably check his oxygen saturation to see what's going on because that's the nursing process you assess first so it says first what would you do chronologically the first thing I would do be check their o2 set but if I'm asking if it's asking for a priority you have to pick an answer that solves the problem so you'd want to sit them up give them oxygen call the doctor whatever the case may be does that make sense okay great yeah so make sure when you're doing your practice questions you pay an attention to that because I know a lot of people mix up first in priority so I want to make sure you keep those straight okay guys well if there's nothing else I'll go ahead and say goodbye for today you guys think of anything else you feel free to email me okay alright guys take care have a good day

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