drenched

Great, thanks so much for the information you guys! I've never understood my paycheck fully even when salaried...so this really shed some light for me :)

Hi, I've been having a really hard time understanding the tax withholdings in each paystub I get & was hoping someone would be able to illuminate me on this. I'm a per diem RN in NYC and work anywhere from 11.5 to 46 hours per pay period (2 week periods). The percentage of tax wittholding varies drastically with each paycheck and leaves me scratching my head. I asked my hospital's payroll department and they just said that the more you work, the higher you get taxed. When I worked 1 shift, I was taxed about 8% (federal) and made about $460 for 1 shift. When I worked 4 shifts, I was taxed about 17% and my pay dropped to $380 for 1 shift. In fact, the % tax rate is different on every pay check. My hourly rate has been the same this entire time. Per diem RNs - is this normal? It just seems ridiculous to me that my pay would drop that much when I work a few more days. Thanks in advance for your help!

Haha whoever designed the emoticons for these boards deserve creativity points Stern advice duly noted! Luckily I haven't seen staff be outright abusive to patients yet...doesn't sound pretty.

Wow, everyone has such good ideas! I second this!! I absolutely love this small binder-big binder system! I had 1 small binder with a section for each class and that'd have all the current notes, and once the test was over, the notes would go into the large binder (also sectioned by class). This is super helpful for not losing your notes for the cumulative final exam (or even just future reference). Also, those plastic folders with 3 holes in them are excellent too! (you know, they're clear, durable, and have a diagonally cut front) I had one for each class and put it in the current binder (also doubles as dividers). These are super handy for putting in hand outs you get from class, and each class's syllabus. This way, you won't lose them before you can 3-hole punch them at home. Also handy for holding things you're about to turn in. I also second (or third, fourth, whatever) the small notebook for clinicals. They fit perfectly into the big pocket in scrub bottoms & are great for taking down report quickly. very handy. Same goes for the organizer! I carried one with me at all times. I'd also recommend getting a giant desk calendar. I had one posted on the wall next to my desk, and wrote in all the important test & due dates on it right after receiving the syllabus from each class. I used magic markers to color code them & this really helped with organization. (because sometimes if you aren't constantly looking in your organizer you won't see some reminders you wrote a long time ago...with a giant desk calendar, all your due dates are right there in your face so you can't possibly forget about them). Best of luck with nursing school!

Um...whoa there. Are you slapping me in the face with a...fish? (??) lol. I agree with everything that you're saying, which is why I specifically said I WOULDN'T engage in belligerence & verbal abuse, and it goes without saying that patient well-being is tantamount. I'm just looking for other options that aren't just standing there & doing nothing, and AREN'T abusive. I asked the question because I figured that with such an experienced populace of RNs on these boards, people would have creative approaches to these situations. (And they do! Thank you all for your advice!) Cheers!

Oh my! o.O And that reminds me of this other 60s-ish lady who was as normal as could be during the day, but unexpectedly sundowned and pulled out her IV and bled everywhere and required 5 nurses to hold her down when she went for her NG tube. She was fiesty! She spat in this one nurse's face and called everyone animals and told us all that we "should be ashamed of yourselves!" and really dug her nails into people and drew blood. The next day she was back to her normal-as-could-be self and didn't remember a thing. She just kept saying "I'm so embarrassed. I can't remember what happened, but I think I might have behaved badly..." She was a very sweet lady too =P

Thanks for the advice. It is very helpful. I will definitely try to cluster care to leave the patient alone. But when constant supervision is necessary it's hard not to interact with them. =/ I guess everyone takes verbal abuse differently. One nurse was belligerent right back to her disoriented patient when he started randomly yelling at her and upped the Haldol. Another nurse was just like "All right dear, I'm sorry you feel that way" when her disoriented patient was yelling "YOURE AN UGLY *****!! BIIIIIIIITTTCH!! LEAVE ME ALONE YOU HAG! I HATE YOU!!" I'm not sure what my style is yet. I don't intend to pick fights with or yell at patients of course, as that's unprofessional. But at the same time, I think I have too much pride to just let someone yell things like that at me, disoriented or not, while all the patients & staff in the unit are listening & cringing.

I'm a pretty logical person, so I become absolutely at a loss when I have a disoriented patient who wants to do something that isn't possible. I haven't started working in the ICU as an RN yet because I just passed my boards this week, but here were some situations I encountered during my ICU externship last year where I didn't really know what to do: Example 1: Lady with breast cancer with mets to the lungs had SIADH. She had a foley in, and 2 chest tubes that pulled out 5L fluid the previous day, was on fluid restriction, and had Na in the 120s. She was a very sweet woman and didn't have hallucinations or anything blatant like that, but her behavior came off as being sort of hysterical at times and ranting & raving. She kept begging me to take out her foley because it was bothering her. But since her major issue was with fluids and Is & Os monitoring would be extremely important, I don't think that would have been a possible option. Also, with Na in the 120s...staff usually don't do the demands of patients who are not likely to be in their right minds. Except that she was technically A&Ox3. And she kept screaming about how she knew her rights, and she knew that she was allowed to refuse treatment if she wanted to and she wanted her chest tube & foley out right now!!! So, I didn't know what to do (and it wouldn't have been my judgment to make anyhow, I was just the student. But also the person who had to talk to this woman face to face for the longest period of time...). I mean, she does have the right to refuse treatment of course...but...what do I say to her? "Sorry, we think you're batty so you no longer have the right to refuse treatment"? I tried explaining why they were necessary, and offered her the morphine that she was prescribed if she had pain, but she didn't care about the explanations and didn't want the morphine. I tried giving her a backrub, distracting her by getting her to tell me stories, and those measures worked for short periods of time. She would get into a story and forget about the chest tube and foley for a while. And sometimes she'd fall asleep. But then she'd suddenly remember that she didn't like them again and start screaming again. *sigh* I was so worn out by the end of that day. What would you all have done? Example 2: Recently extubated COPD patient was definitely disoriented. Kept insisting that I "check her mail" that was "right over there! Don't you see it!! WHY WONT YOU CHECK MY MAIL??". She got really aggravated with me because I wouldn't let her climb out of bed to go to the bathroom (fall precautions, had a foley in). I tried explaining to her that she had a catheter sitting in her bladder, and that she wasn't supposed to climb out of bed yet, but she was to confused to understand. So she was all like "help me put on my shoes so I can go to the bathroom" and "why are you aggravating me????" when I tried to keep her from climbing out of bed. *sigh* another tiring day. I tried combing her hair, distracting her, etc etc. but it didn't work for more than 2 minutes. What do you do with patients who are constantly trying to climb out of bed and picking at their lines and get really mad at you for trying to stop them from doing that? Do you just suck it up when they yell at you to "shut up" and "leave me alone" and keep at it? I mean...you can't very well just let them get out of bed or pull out their IV right? So what do you do? Advice would be extremely appreciated. Thanks, Newbie ICU nurse

Agreed! I think you're ready =) I only got about 60% on the Q bank and right above borderline on the exit exam from kaplan (dont remember the percentage), and I just passed 2 days ago in 75 questions. At this point, I don't think another bout of studying will help you...Kaplan can only do so much. There were a bunch of questions that none of Kaplan's strategies would help with anyway, so might as well just get it over and done with. Good luck! I know you'll do fantastically =)

Oh man. Do I ever know what you mean. I just took my boards today and I really don't think I did well at all. There were very few answers that I put down that I was sure of. And to top it off, I have a job lined up for the beginning of September, so I won't have enough time to take it again if I did fail. =/ *fingers crossed for all of you*, ~drenched

Oh whew. Thanks you guys! I'm always able to hear it, but I thought we had to be able to palpate it too. Good to know I'm not entirely insane in not being able to feel it! =P

Hi all. I know that the Apical Pulse or PMI or mitral valve or whatever you want to call it is located at the left 5th intercostal space, midclavicular line. Right? Well I can never seem to feel it. Because on women, it's where their boobs are! And on men, they've got a huge pile of muscle there. And I know if you can you're supposed to try to lift the breast out of the way right? But unless I'm mistaken, it's smack dab under it a lot of the time. I'm as skinny and flat-chested as they come, and I have trouble finding it on myself. Any tips? =/ Thanks, drenched P.S. Ahhh....my boards are in 9 hours! *scurries off to cramming*

Ours is a locked unit that only unlocks during visitor hours, which are half an hour every odd hour during the day shift.

YES! I'm just a new grad and haven't even passed my NCLEX yet, but after externing in the ICU for 3 months I filled out a living will. Mine was through an organization called NYLAG, which puts your living will in a database so that hospitals can access it easily if they need to. Basically I said: - i want everything curative if there is reasonable hope of recovering higher brain function. - But if I was brain dead or a vegetable or in a coma and not expected to recover, I wouldn't mind withdrawal of care. i.e. I DONT want a full code, I don't want a new intubation, I'm okay with being put on morphine even if it hastens death, it's okay to take away my pressors, you can have my vital organs, you can take out my NG tube, but I want antibiotics (not sure of my reasoning there...it just seemed all right). - If I'm in a coma with a very very slim chance of recovery but it's unlikely, I give permission to take me off life support & curative measures after 3 months. (This isn't a demand, it's just permission so my family won't feel guilty and won't rack up a huge indefinite bill). The case that made up my mind was this elderly woman post mitral valve replacement who developed ischemic bowel that wasn't caught in time and was unconscious and had a lactate of >15 by the time my preceptor was assigned to her. The first thing my preceptor said to me when we entered the room was "she's dead already." And I was confused because we see a lot of unconscious patients in the ICU and she looked just about as unconscious as the next guy but not necessarily "more dead." But then again I'm very green and haven't seen too many dead people yet in my day. But the nurse just kept saying "she even LOOKS dead...she's going to crash today." The poor RN was super stressed with all the pumps and everything and the patient coded that afternoon and I'll never forget the sight of all the staff chaotic around her bed, doing CPR to this poor old woman's body until she was vomiting feces because she wasn't DNR. They got a spontaneous rhythm back but I remember thinking "so what? she's not going to get better." The only difference it made was that she had a rhythm for 3 more hours until she coded again and died. And that's why I have a living will. =/

hi! I'm a third year undergrad nursing student, and just started clinicals. I'm having a bit of trouble reading the cardex, especially the abbreviations. question: what does the following mean? lcx s/p mvr abd tee i tried to look it up in the dictionary, but it either wasn't there or there were so many possible things they could mean that it didn't really help me much. i just had no idea what this means: "s/p cath shows rca severe mid lesion, lad 60-65% proximal lesion, lcx mod. proximal disease" it looks like it could mean suprapubic catheter, but my patient is continent of urine & all that, is it for something else if that's what it means at all? i also have no idea what this means: "pt noted with new onset afib.plan for ?tee/echo." the cardex also said: "10/14s/p tee: severe MI, mild-mod TI, mod pulm HTN [etc.]" it's the first part that confused me...it looks like it means that the pt had a severe myocardial infarction on 10.14. however, my patient looked just fine on 10/22 with no pain, no mention of it at all, perfectly coherent etc. so i have a feeling that MI doesn't mean heart attack here. is there anything else this could be? sorry for so many questions. thanks so much for reading!