In this high-yield episode, we take you straight into the heart of NCLEX pharmacology—the Dirty 60 prototype drugs and the red-flag safety scenarios that appear again and again on the exam. Instead of drowning in endless medication lists, you’ll learn how to recognize the life-threatening patterns the NCLEX actually tests: respiratory depression from opioids, bleeding risks with anticoagulants, angioedema from ACE inhibitors, ototoxicity with aminoglycosides, digoxin toxicity, magnesium overdose, and more. Brooke breaks down the nine essential antidotes every student must memorize, the priority nursing actions tied to each high-alert drug class, and the deadly IV-push rules the NCLEX loves to trap students with. You’ll also get a step-by-step, 8-week study plan designed to raise your pharmacology score into the safe zone and build real clinical judgment. This episode is all about clarity, confidence, and protecting your patient. Master the Dirty Sixty, know the red flags cold, and you’ll transform NCLEX pharmacology from a source of fear into one of your strongest categories.
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EPISODE NOTES
Largest and most feared NCLEX subsection.
Students may face 20–50+ pharm questions in a row.
Scoring under 58% on pharm practice drops first-time pass chance to ~30%.
NCLEX repeatedly tests the same 15–20 high-danger scenarios, not broad memorization.
Stop memorizing hundreds of drugs.
Master the 60–70 prototypes (“Dirty 60”) and the red-flag dangers they carry.
NCLEX focuses on:
Immediate safety threats
Priority nursing actions
Reversal agents
Toxicity signs
Safe administration rules
You will see 1–3 antidote questions on the NCLEX.
High-Alert Drug
Antidote
Heparin
Protamine sulfate
Warfarin
Vitamin K; FFP if actively bleeding
Opioids
Naloxone
Benzodiazepines
Flumazenil
Acetaminophen
Acetylcysteine
Digoxin
DigiBind
Magnesium sulfate toxicity
Calcium gluconate
Beta-blocker overdose
Glucagon
Opioids: morphine, hydromorphone, fentanyl
Anticoagulants: heparin, enoxaparin, warfarin, one DOAC (apixaban)
Insulins: regular, NPH, lispro, glargine
Metformin
Digoxin
Amiodarone
Adenosine
Dopamine
Nitroglycerin
Metoprolol
ACE inhibitors (lisinopril, enalapril)
ARBs (losartan)
Hydralazine
Phenytoin
Valproic acid
Levetiracetam
Magnesium sulfate (OB + seizure)
Vancomycin
Gentamicin
Tobramycin
Ceftriaxone
Lithium
Major antipsychotics
Acetaminophen
Potassium chloride
Albuterol
Levothyroxine
Action:
Stop infusion immediately
Give naloxone
Stay with patient
Red flag: platelets <100,000
Action:
Stop heparin
Label as allergic
Notify provider
Never give aspirin
Airway emergency
Action:
Stop ACE inhibitor for life
Never restart any drug in the class
Flushing during infusion
Action:
Slow rate to 90–120 minutes
Pre-treat with antihistamine
Not a true allergy
Ringing, hearing loss
Action:
Stop drug
Notify provider
Check peak/trough levels
Red flags:
Yellow/green halos
HR <60
Severe N/V
Action: Holds dose, check dig level, notify provider
Red flags:
Any imaging with IV contrast
Muscle pain + drowsiness → lactic acidosis
Action:
Hold 48 hours before & after contrast
Monitor kidneys
Red flags:
Respiratory depression
Loss of reflexes
Action:
Give calcium gluconate
Dose calculations:
Desired ÷ Have × Vehicle
IV drip rate:
Total Volume ÷ Time in minutes × Drop factor
Never IV push undiluted potassium chloride (instant cardiac arrest)
Fentanyl/morphine: push over 4–5 minutes
Adenosine: must be pushed in 6 seconds, followed by rapid flush
Blood transfusion:
Two nurses verify
Stay with patient for first 15 minutes
Memorize Dirty 60
Memorize antidote list
Use Anki/Quizlet
No practice questions yet
50 dosage calcs per day
Build accuracy + speed
100 pharm questions per day
Read every rationale
Watch Simple Nursing, Mark Klimek
Only focus on high-yield drug classes
Mixed blocks
Track pharm separately
Goal: 65%+ (UWorld 70–80%)
Dirty 60
Antidote chart
IV push rates + insulin peaks
Why push fluids?
Because lithium is excreted entirely through the kidneys.
Hydration increases clearance and prevents worsening toxicity.
Welcome to Think Like a Nurse. This show was created by Brooke Wallace. She's a 20-year ICU nurse, an organ transplant coordinator, a clinical instructor, and a published author.
And our mission here is really focused. We take these uh huge complex nursing topics, and we just break them down.
Exactly. We make them easier to understand so you can actually use the knowledge and, you know, crush the NCLEX. For more, definitely visit think like a nurse.org.
So, today we are staring down the beast, the single most uh intimidating subcategory on the entire exam. Pharmarmacological and parental therapy.
Oh, that's the one. That is the section that strikes fear into the heart of every nursing student. I bet you listening right now are just nodding along.
You're thinking about staring at your screen and seeing 20, 30, maybe even 50 plus farm questions in a row. It just feels impossible.
It does. It absolutely does. But let's just start with the data. The reality of it. U data from this year and next shows a really clear line.
Okay.
If you score below 58% on your pharmarmacology practice, questions. Your chance of passing the NCLEX on the first try just it drops off a cliff. Wow. Down to around 30%. So this isn't just a hard section. It's like the gatekeeper.
That is a staggering statistic. So okay, if the sheer volume of information, I mean hundreds of drugs, thousands of side effects is what causes the panic. What's the way out? What's the strategy?
You have to pivot. You pivot from breath to depth. I'm telling you, this section is so conquerable, but only if you completely abandon the idea of memorizing 500 drugs.
Okay, stop memorizing.
Stop.
Instead, you focus on the 60 or 70 really high yield drugs. And this is the key, the immediate dangers they present.
All right, I'm going to challenge you on that a little bit because when I open my textbook, right, I see diuretics, beta blockers, statins, all with 10 different names and a million different side effects.
How can I possibly justify ignoring 400 of those drugs?
Because the NCLEX isn't testing you on being a pharmacist. It's testing you on being a safe nurse
it recycles the same 15 to 20 uh really dangerous red flag problems over and over again.
Why? Because those are the ones that require immediate life-saving nursing action, right?
If you master those high alert scenarios and you get the antidote chart down cold, you've basically won the battle for all those what's the priority action questions.
This is where it gets good. Let's prove it right now.
Yeah.
When we say critical red flags, what are the first few that should just pop into your head instantly.
Instant recognition is everything. We're talking about the patient on opioids whose respiratory rate just tanks, falls below eight.
Okay.
We're talking about, you know, any kind of excessive bleeding in someone on an anti-coagulant.
Yeah.
Or that really scary angiodma, the sudden swelling of the face, the throat with AC inhibitors.
And what about that weird one with the vision?
Yes. The bizarre but classic yellow or green halos that tell you your patient is toxic from dyin.
These are scenarios where you stop thinking and you start acting. It totally shifts the focus from how does the drug work to what does my patient need right now?
Precisely. And the absolute fastest win you can get is locking down the reversal agents, the antidote.
Guaranteed questions, right?
You are absolutely guaranteed one to three questions on these. This is pure memorization, but it's a short super high yield list.
All right. If it's showing up on every exam, we have to know a cold. Let's go through the pairings. What are they?
Okay, let's do it. High alert drugs for antiquagulants. You've got two big ones. Heparin is reversed with protein sulfate.
Got it. Heparin protein sulfate
and warpherin which is slower is reversed with vitamin K or if they're actively bleeding out fresh frozen plasma FFP.
And the classic ones the CNS depressants that stop breathing
right for opioids it's nlloxxone. You have to give it immediately. For bzzoazipines think you know laora zapam alpolivam the antidote is fluminol.
Okay.
Then for an acetaminophen overdose you need acetal ine and for that dioxin toxicity we mentioned if it's severe you give digi bind
and what about that high alert one you see it a lot in OB
magnesium sulfate for preeacclampsia if that patient becomes toxic their reflexes disappear breathing slows way down the immediate reversal is calcium gluconate
calcium gluconate
and one last one if a patient is crashing from a massive beta blocker overdose the drug we use is glucagon that whole list it's less than 10 pairs it's high yield gold
that simplifies things so so much. So now let's apply that same filter to the drugs themselves. You call them the dirty 60.
That's right. The idea is to focus on the prototype drug in each major class.
So you learn one and you basically learn the whole family.
You master the prototype, you understand the core mechanism, the main side effect, and the big red flag for the entire class.
Yeah.
Let's just, you know, quickly outline the groups you need to hit first.
Let's do it. Start with pain management and blood thinners.
For opioids, you need morphine, hydromemorphone, and fentanyl. For cocoagulants. The big four are hepin, annoxiperin, warpherin, and then one of the newer ones like a pixaban.
Okay. And on the endocrine side, diabetes is always always heavily tested.
It's critical. You have to know the timing, the onset, peak, duration for the four main insulins, regular, and ph, lispro, and glargene.
Rapid and long acting.
Yep. And you absolutely need to know metformin, the oral workhorse.
Then we get to the heart drugs. These always have complicated names and rules.
So for the big cardiac meds, Digoxin, amiodarone, adenosine, that's the chemical defibrillator, dopamine and nitroglycerin.
And for the anti-hypertensives, just think in classes,
metoprol, that's your beta blocker,
leanicrol,
your acce inhibitor, lartin and arb and hydrolysine.
And for nervous system safety,
anti-seizure meds like cenitoin, theproic acid, levitatorum, and of course, magnesium sulfate. Again, for antibiotics, the dangerous ones are vencomyin, gentamison, and septrioxone.
Okay. In psych it's lithium and the major antiscychotics and then just a few miscellaneous ones acetaminophen, potassium chloride, albuterol and levothyoxine. If you know those 60, you are in such a good place.
Okay, so we've covered the what the drugs, the antidotes. Now for the how, the priority action questions. Let's pivot to those specific red flag scenarios.
This is what dictates the right answer. Let's start with the most common one, opioids. We mentioned respiratory depression,
right? So the red flag is a respiratory rate that drops below 8 to 10. What is the absolute priority action. There's no thinking. You act. Stop the infusion right now. Give Nlloxxone and this is critical. You stay with the patient. You do not leave their side. Okay. Next up, Heperin. You mentioned bleeding, but what's the lab value? The internal red flag that tells you to stop it. The big test scenario is HIT. Hepin induced thrombocytoenia. This is where the platelet count just tanks. Usually falls below 100,000. And the action. Stop the heperin immediately. Label the chart that they're allergic. are sensitive notify the provider and whatever you do do not give aspirin that would be huge mistake
let's talk about blood pressure meds AC inhibitors lizinopriil enaloperal I know they cause that annoying dry cough but what's the actual life-threatening red flag angiodma that swelling of the lips face tongue this is an airway emergency about to happen well the action has to be decisive it is uncompromising stop the AC inhibitor for life the patient can never take any drug in that class ever again it's a crucial distinction That's the key safety distinction. Okay. Now, let's compare that to vancomy the third. You get that classic red man syndrome flushing red rash on the face and neck. Why is the action here so different from the ACE inhibitor?
Because red man syndrome is usually just an infusion reaction. It's a histamine release, not a true life-threatening allergy like angiodma. Okay, so the red flag is the flushing during the drip. What do you do? You don't stop it forever. You just slow the infusion rate. Take it down to 90 or 120 minutes and next time you pre-treat with an antihistamine like benadryil. This is such a classic trap question. That makes perfect sense. The severity dictates the action. What about the aminoides? Drugs like gentamison and tobery. They have a known toxicity the nleex loves.
Yes, major safety point here. The red flag for these is autototoxicity, ringing in the ears or any new hearing loss. These drugs are really hard on the ears and the kidneys. So the action is stop the drug, notify the provider and check your peak and trough. levels. If that trough level is too high, the patient is basically just bathing their kidneys in toxin that can cause permanent damage. Let's hit two more really quick. Digin toxicity. Red flag. Those yellow or green halos in their vision, heart rate below 60, or just severe nausea and vomiting
and the action. You hold the dose, check the deoxin level, and call the provider. Simple as that. And metformin, the common diabetes drug. When does it become dangerous? The red flag is if your patient is scheduled for any kind of imaging study that uses IV contrast die, right? Or if they suddenly get muscle pain and deep drowsiness, which could be lactic acidosis, the action is strict. You hold metformin for 48 hours before and after that contrast eye procedure. Okay, moving away from the clinical scenarios, we have to talk calculations and IV rules. Students really freak out about this.
They do, but it's usually only four to eight questions. There are guaranteed points if you just practice. Yeah. The mistake is trying to learn like 10 different formulas. So, keep it simple. So simple. Do 50 practice calculations every single day until you can do them in your sleep. Repetition is everything. And you said we only really need two core formulas. That's it. For your tablets or liquids, it's just desired over half times your vehicle. And for 5V drips, it's total volume divided by time in minutes multiply by the drop factor. Y,
that's it. Beyond the math, the IV push rules are often life or death. And I know the NCLEX tests the lethal errors. What is the absolute number one rule? Never ever Never under any circumstances IV push undiluted potassium chloride. Why not? It causes instant cardiac arrest. If you're giving it on a medical floor, the max safe rate is usually 10 to 20 millu per hour. And anything faster absolutely requires cardiac monitoring.
And what about the push rates for pain meds and cardiac arrest drugs? Fentinyl and morphine have to be pushed slowly over four to five minutes to avoid that respiratory collapse. And then the opposite is true for another drug. Exactly. Contrast that with adenosine. That drug has to be pushed in 6 seconds flat, followed immediately by a fast saline flush because it's a halflife is only like 10 seconds. Wow. And the high stakes procedure rules, blood transfusions. Two nurses, two nurses have to verify the blood at the bedside. And the nurse giving it must physically stay with that patient for the first 15 minutes to watch for a reaction.
Okay, we've broken down the strategy, the drugs, the rules. For the person listening right now who's in the middle of studying, let's give them the road map, the 8-week success plan. This is how you turn that fear into competence. Weeks one and two. Your only job is to learn the content. Memorize the dirty 60 prototypes and that antidote chart. Use Anki. Use Quizlet. Don't even touch questions yet.
Weeks three and four. Shift gears completely. It's all about calculations. 50 dosage calcs every single day. That builds speed and accuracy.
Weeks five and six, this is where you do the deep work. 100 pharmarmacology only questions a day from your question bank. And you have to read every single rationale, even for the ones you got right.
Week seven is for putting it all together.
Yep. Content consolidation. Listen to lectures like Mark Cleick. Watch simple nursing videos, but only on the high yield drug classes we just listed.
And the final week,
week eight, you transition to mixed question blocks, but you track your pharmarmacology score separately. The goal is to consistently hit 65% or higher on just those farm questions. If you're using UWorld, you should be aiming for that 70 to 80% range. That's your safety zone. And practically speaking, you should print out three one-page cheat sheets, right?
Yes. Have them visible. One with the dirty 60 and high alert meds, one with the antidote chart, and one with those critical IV push rates and insulin peaks. If you follow that plan, it really will transform pharmarmacology from a weakness into a strength. It's all about that strategic shift from endless memorization to mastering the red flags. It's about safety. This has been a phenomenal breakdown. We hit the dirty 60, the nine guaranteed antidotes. and the biggest red flag priority actions. It really proves you need strategy, not just brute force.
So before we sign off, here's one final thought for you to chew on this week. It connects back to the psych meds. We mentioned lithium toxicity, which causes confusion and a coarse tremor. We said the priority action is to hold the drug, check the level, which is normally 6 to 1.2, and push fluids. So here's the question. Why is pushing fluids promoting hydration so specifically crucial in Managing lithium toxicity. Think about how your body gets rid of lithium. That is a great safety question to think about. This discussion should really give everyone listening the confidence and the tools to attack farm questions strategically.
We've moved you away from those overwhelming lists and toward focusing on what really matters, concrete, life-saving nursing actions. Thank you so much for joining us. We hope you'll check in for more conversations each week. And don't forget to visit think like a nurse.org for all the resources you need to succeed. You've got this.