NCLEX-PN® Examination flashcards

A worsening of asthma symptoms (wheezing, cough, dyspnea, chest tightness) requiring immediate intervention to relieve bronchospasm and inflammation.

• First-line treatment: Short-acting beta-agonists (SABAs) like albuterol.
• SABAs provide rapid bronchodilation.
• Systemic corticosteroids (e.g., prednisone) are used to reduce inflammation in moderate to severe exacerbations.
• Oxygen therapy may be needed to maintain adequate saturation.

Memory trick: Asthma Attack: Albuterol First, Breathe Better Fast!

Adaptive aids for self-feeding are specialized utensils or dining equipment designed to help individuals with motor impairments or disabilities maintain independence during meals.

• Aids compensate for fine motor deficits.
• Promote dignity and independence.
• Selection is based on specific client needs.

Memory trick: Plate Guard for Parkinson's Progress.

Non-selective beta-blockers, such as propranolol, are contraindicated in clients with asthma or COPD due to their potential to induce bronchoconstriction by blocking beta-2 adrenergic receptors in the lungs.

• Propranolol is non-selective.
• Blocks beta-1 (heart) and beta-2 (lungs) receptors.
• Beta-2 blockade causes bronchoconstriction.
• Dangerous for clients with asthma/COPD.

Memory trick: PROPRANOLOL: Pulmonary Risk, Obstructive Respiratory

Techniques and principles used to safely move clients between surfaces, minimizing risk of injury to client and caregiver.

• Assess client's strength and ability before transfer.
• Use proper body mechanics for the nurse.
• Position wheelchair on client's stronger side for pivot transfers.

Memory trick: Weak side needs your presence, strong side does the work.

For clients designated NPO, all oral intake, including medications, requires explicit clarification from the healthcare provider or RN due to the risk of aspiration or interference with the medical procedure.

• NPO means nothing by mouth.
• Certain medications (e.g., cardiac, seizure) may be allowed.
• Always clarify with provider/RN.
• Risk of aspiration or surgical delay.

Memory trick: NPO: Not Permitted Orally, Provider Order!

The process of choosing the correct needle gauge and length for a subcutaneous injection, aiming to deposit medication into the adipose tissue layer beneath the dermis while minimizing pain and tissue damage.

• Gauge: 25-30 G (smaller numbers = larger diameter).
• Length: 1/2 to 5/8 inch (12-16 mm).
• Injection angle: 45 or 90 degrees, depending on client's body fat.
• Common sites: abdomen, outer aspect of upper arms, thighs.

Memory trick: Gauge Goes Small, Length is Short for SubQ

Strategies to avoid skin and tissue damage caused by prolonged pressure, shear, and friction.

• Frequent repositioning is key for immobile clients.
• Maintain good nutrition and hydration.
• Keep skin clean, dry, and moisturized.

Memory trick: Turn the body, feed the skin, keep it clean and dry.

Regular and systematic assessment of a client's physical and psychological status while in restraints to ensure safety and minimize adverse effects.

• Assess neurovascular status (CSM: circulation, sensation, movement) every 15-30 minutes.
• Check skin integrity under and around restraints.
• Provide range of motion, toileting, nutrition, and hydration every 2 hours.
• Reassess need for restraints frequently.

Memory trick: Restrained? Check the Blood Flow, Don't Let Injury Grow!

Proactive and reactive strategies to prevent and manage allergic reactions to latex, including creating a latex-safe environment and educating clients and staff.

• Identify and mark clients with latex allergy.
• Use latex-free products for all care.
• Be aware of hidden latex in equipment.
• Anaphylaxis is a severe potential reaction.

Memory trick: Latex-Free Life for Lungs

Providing a bed bath requires careful attention to client comfort, privacy, and safety, especially regarding temperature regulation and exposure.

• Maintain client's body temperature.
• Ensure privacy and dignity.
• Use warm water and gentle techniques.

Memory trick: Warmth Wrapped, Dignity Draped.

Methods to reduce pain that do not involve medications, often used as adjuncts to pharmacological treatments.

• Include distraction, guided imagery, relaxation, massage, hot/cold therapy.
• Effectiveness varies by pain level and individual preference.
• Often more effective for mild to moderate pain or as adjuncts for severe pain.

Memory trick: Mind over matter helps when meds are on board.

Choosing the correct needle gauge and length for intramuscular injections based on medication viscosity, client's body habitus, and injection site.

• Viscous meds need larger gauge (smaller number).
• Needle length depends on client size and site.
• Adult IM: 1-1.5 inch length common.

Memory trick: Gauge for Go, Length for Location, Viscosity for Velocity!

A syndrome characterized by a sudden, massive reflex sympathetic discharge in response to stimuli below the level of spinal cord injury (T6 or above), leading to severe hypertension.

• Occurs in spinal cord injury at T6 or higher.
• Symptoms: pounding headache, profuse sweating (above injury), nasal congestion, piloerection, severe hypertension.
• Common triggers: full bladder or bowel, tight clothing, skin irritation.
• Immediate action: elevate head of bed, identify and remove stimulus.

Memory trick: Dysreflexia: Head Pounding, BP Soaring, Find the Trigger!

The practice of pulling back on the syringe plunger after needle insertion but before medication injection to check for blood return.

• Prevents accidental intravascular injection.
• Not required for all IM injection sites or medications (e.g., vaccines).
• If blood is aspirated, withdraw the needle and prepare a new injection.

Memory trick: Inject Smart, Aspirate First, No Vein Burst!

Administration of the anticoagulant enoxaparin via the subcutaneous route to prevent or treat thromboembolic disorders.

• Preferred site: abdomen.
• Inject 2 inches from umbilicus.
• Do not expel air bubble from pre-filled syringe.

Memory trick: Sub-Q shots: Think Belly, Arms, Thighs – Abdomen is the Best for Blood Thinners!

Calculation of drops per minute (gtt/min) for a manual intravenous infusion using total volume, infusion time, and the tubing's drop factor.

• Formula: (mL/min) * gtt/mL.
• Convert hours to minutes.
• Round to nearest whole number.

Memory trick: Volume, Time, Drop Factor: The Trio for Drip Rate Action!

Calculating the infusion pump rate (mL/hour) when a specific volume is to be infused over a given time.

• Formula: Total Volume (mL) / Total Time (hours).
• Result is in mL/hour.
• Used for medications or fluids with a specified infusion duration.

Memory trick: V/T: Volume over Time

Warfarin is an anticoagulant that has numerous significant interactions with herbal supplements, which can either increase or decrease its anticoagulant effect, leading to serious adverse events.

• Many herbals (e.g., St. John's wort, ginseng, ginkgo, garlic) interact with warfarin.
• Interactions can alter the International Normalized Ratio (INR).
• Clients should always inform their provider about all supplements they are taking.

Memory trick: Warfarin's Weakened by Wild Herbs

The process of adding moisture to supplemental oxygen to prevent drying and irritation of the client's respiratory mucous membranes, especially at flow rates of 2-4 L/min and above.

• Prevents dryness, epistaxis, and discomfort.
• Uses sterile water to prevent bacterial growth.
• Reservoirs should be checked regularly and refilled as needed.

Memory trick: Humidify to Halt Harshness

Specific personal protective equipment required when caring for clients with diseases transmitted by small airborne droplets.

• N95 or higher-level respirator is mandatory.
• Gloves and gown are typically used for all direct patient care.
• Private room with negative-pressure airflow is also required.

Memory trick: Don't Let Germs Fly, Droplet, Contact, or Air HIGH!

The process of draining contents from an ostomy pouch to maintain hygiene and prevent leakage.

• Empty when 1/3 to 1/2 full.
• Clean the tail of the pouch thoroughly.
• Securely close the clamp or roll-up system.

Memory trick: Empty, clean, clamp, then live your day.

Furosemide, a loop diuretic, primarily causes significant potassium excretion, leading to a risk of hypokalemia, especially in clients with heart conditions.

• Loop diuretic.
• Causes potassium loss.
• Risk of cardiac arrhythmias with hypokalemia.
• Monitor potassium levels closely.

Memory trick: Furosemide: Fluid Out, Potassium Low

Measures taken to reduce the spread of the influenza virus from person to person.

• Hand hygiene (washing or sanitizing) is crucial.
• Cough and sneeze etiquette (into elbow or tissue).
• Avoid close contact with sick individuals.
• Do not share personal items (utensils, glasses, towels).

Memory trick: Flu Fighters: Wash, Cover, Distance, Don't Share!

When TPN infusion is interrupted or runs out, Dextrose 10% in water (D10W) should be administered at the TPN's previous rate to prevent rebound hypoglycemia.

• TPN is high in dextrose.
• Abrupt cessation causes rebound hypoglycemia.
• D10W provides temporary glucose.
• Administer D10W at the TPN's ordered rate.

Memory trick: TPN OUT: Temp D10W, Prevent Hypo

An adverse reaction to rapid intravenous infusion of vancomycin, characterized by flushing, rash, pruritus, and hypotension, primarily affecting the face, neck, and upper torso.

• Caused by rapid vancomycin infusion.
• Symptoms: flushing, rash, pruritus, hypotension.
• Not an allergic reaction, but a histamine release.
• Management: stop infusion, slow rate for future doses.

Memory trick: RED MAN: Recognize, Emergency, Discontinue, Management, Assess, Notify

Measures taken to prevent fires and burns in the home when supplemental oxygen is in use, focusing on eliminating ignition sources and maintaining safe distances.

• Oxygen is combustible, not flammable, but supports combustion.
• No smoking or open flames near oxygen.
• Keep oxygen at least 5 feet from heat sources.
• Avoid petroleum-based products.

Memory trick: Oxygen's Ongoing Safety

An excess of fluid in the extracellular compartment, often caused by compromised regulatory mechanisms (e.g., heart failure, kidney failure) or excessive intake.

• Causes include heart failure, kidney failure, excessive IV fluid administration.
• Symptoms include edema, crackles, shortness of breath, weight gain, elevated blood pressure.
• Treatment focuses on fluid restriction, diuretics, and addressing the underlying cause.

Memory trick: Too Much Water, Heart Can't Hold It!

Selecting the appropriate intramuscular (IM) injection site and needle based on client age, muscle mass, medication volume, and medication type to ensure safety and efficacy.

• Ventrogluteal is preferred for adults.
• Avoid dorsogluteal due to sciatic nerve risk.
• Needle length depends on site, client size, and muscle mass.
• Gauge depends on medication viscosity.

Memory trick: IM: Inject Muscle Safely

The practice of creating and preserving an area free from all microorganisms during invasive procedures to prevent infection.

• All items within the sterile field must be sterile.
• Edges of a sterile field are considered contaminated.
• A sterile field must never be turned away from or left unattended.
• A contaminated hand must not touch sterile items.

Memory trick: Sterile Stays Safe, Separated

Specific infection control measures, primarily contact precautions, implemented to prevent the transmission of C. diff spores, which are highly resistant and spread through the fecal-oral route.

• Requires contact precautions (gown and gloves).
• Hand hygiene with soap and water is crucial for spore removal.
• Environmental cleaning with bleach-containing disinfectants is necessary.

Memory trick: An Droplet Contact Standard

Management of an artificial airway in the trachea, including assessment, cleaning, and suctioning to maintain patency and prevent complications.

• Suctioning is performed to remove secretions and maintain airway patency.
• Signs of need for suctioning include adventitious breath sounds, visible secretions, ineffective cough, decreased SpO2, increased WOB.
• Sterile technique is crucial for tracheostomy suctioning to prevent infection.

Memory trick: Trach Tube Trouble? Clear the Clutter, Get Air!

The insertion of an indwelling urinary catheter into a male client's bladder requires specific techniques to navigate the longer, curved urethra safely and comfortably.

• Aseptic technique is paramount.
• Extensive lubrication is crucial.
• Balloon inflation only after urine return.

Memory trick: Lube Long, No Lacerations, Look for Liquid.

The process of safely defrosting frozen food to prevent bacterial growth, primarily through methods that keep food out of the 'danger zone' (40°F-140°F or 4°C-60°C).

• Never thaw food at room temperature.
• Safe methods: refrigerator, cold water (changed every 30 mins), microwave.
• Cook food immediately after thawing in cold water or microwave.

Memory trick: Clean, Separate, Cook, Chill

Key safety steps to follow when operating an Automated External Defibrillator to prevent harm to rescuers and bystanders.

• Ensure client is dry and on a non-conductive surface.
• Apply pads correctly.
• Clear everyone before analysis and before shock delivery.
• Announce 'CLEAR!' loudly.

Memory trick: AED Shock? Clear the Area, Don't Be a Bear!

A severe complication of diabetes characterized by hyperglycemia, ketosis, and metabolic acidosis, primarily due to profound insulin deficiency.

• Primary acid-base imbalance is metabolic acidosis.
• Low pH (<7.35) and low bicarbonate (HCO3 <22 mEq/L).
• Compensatory mechanism is Kussmaul respirations (hyperventilation), leading to low PaCO2 (<35 mmHg).

Memory trick: DKA = Down pH, Down Bicarb, Down CO2 (compensating)

A disorder caused by ADH deficiency or renal insensitivity to ADH, leading to excessive excretion of dilute urine and profound thirst.

• Cardinal symptoms: polyuria (up to 20 L/day) and polydipsia.
• Urine specific gravity is very low (<1.005).
• Serum osmolality is high (>295 mOsm/kg) due to dehydration.
• Serum sodium is often high (hypernatremia).

Memory trick: DI = Dry Inside, Dilute Out!

Calculation of intravenous dopamine infusion rate (mL/hr) based on client weight, ordered dose (mcg/kg/min), and available drug concentration.

• Convert lbs to kg.
• Convert mg to mcg.
• Use dimensional analysis for accuracy.

Memory trick: Weight, Dose, Concentration, Time: The Rhythm for IV Calc Rhyme!

A blockage within a nasogastric tube that prevents fluid or medication from passing through.

• Common causes include crushed medication residue, formula, or tube kinking.
• Initial interventions focus on gentle methods like repositioning and gentle flushing.
• Forceful flushing or unapproved solutions should be avoided to prevent complications.

Memory trick: NG Tube Stuck? Reposition, Then Gently Chuck!

The systematic process of putting on personal protective equipment (PPE) in a specific order to prevent self-contamination and the spread of infection, particularly when caring for clients on contact precautions.

• Always don PPE before entering the client's room.
• The order of donning minimizes contamination risk.
• Gloves are always the last item to be donned.

Memory trick: Go Make Every Glove

The most critical safety check before administering a blood transfusion is the two-person verification of client identity and blood product compatibility to prevent ABO incompatibility reactions.

• ABO incompatibility can lead to severe, life-threatening hemolytic reactions.
• Two-person verification is a mandatory safety protocol.
• Check blood type, Rh factor, unit number, expiration date, and client's name/DOB.

Memory trick: Two nurses check, right blood, right patient, no regret!

The critical phase of dengue fever, signaled by defervescence, is when plasma leakage, shock, and severe organ impairment are most likely to occur, requiring vigilant monitoring.

• Dengue has three phases: febrile, critical, and recovery.
• Defervescence marks the transition from febrile to critical phase.
• Plasma leakage leads to ascites, pleural effusion, and hypovolemic shock.

Memory trick: Fever Falls, Fluid Leaks, Fatal Fates.

Acting on behalf of clients with substance use disorder to ensure their rights are protected, their needs are met, and they have access to appropriate resources for recovery.

• Involves empowering clients to make informed decisions.
• Focuses on providing resources and support, not judgment.
• Upholds confidentiality and respects client autonomy.

Memory trick: Advocacy is offering aid, not admonishing or abandoning.

Pharmacologic management of cardiogenic shock focuses on improving cardiac output, blood pressure, and tissue perfusion, often utilizing vasopressors and inotropes.

• Cardiogenic shock is characterized by severe pump failure.
• Goals are to increase myocardial contractility and systemic vascular resistance.
• Norepinephrine is a common first-line agent, often combined with dobutamine.

Memory trick: Norepi for shock, makes the heart's pump rock!

The ethical and legal obligation of healthcare providers to protect client information and not disclose it to unauthorized individuals without the client's explicit consent.

• Protected by HIPAA (Health Insurance Portability and Accountability Act).
• Applies to all protected health information (PHI).
• Client consent is required for disclosure to family, friends, or other non-care team members.

Memory trick: Confidentiality is a closed door, unless the client says 'come in'.

A partnership between a group of healthcare professionals from various disciplines who work together to achieve common goals for client care.

• Enhances client outcomes through shared knowledge and skills.
• Requires effective communication, mutual respect, and shared decision-making.
• Involves regular meetings, handovers, and shared documentation platforms.

Memory trick: Teamwork thrives on shared truths, written for all eyes.

Thyroid storm is a life-threatening hypermetabolic state requiring urgent treatment to block thyroid hormone synthesis, block hormone release, manage symptoms, and provide supportive care.

• PTU is preferred over methimazole in thyroid storm due to its additional effect of blocking T4 to T3 conversion.
• Iodine solution must be given after PTU.
• Beta-blockers control cardiovascular symptoms.

Memory trick: PTU Prevents Production, Propranolol Protects.

Severe diarrhea can lead to significant fluid and electrolyte disturbances, primarily hypovolemia and metabolic acidosis due to loss of bicarbonate-rich fluids.

• Diarrhea causes loss of water, sodium, potassium, and bicarbonate.
• Hypovolemia results from fluid loss, leading to hypotension and tachycardia.
• Loss of bicarbonate leads to metabolic acidosis.

Memory trick: Diarrhea's drain makes volume low, acid high, a fluid woe!

Healthcare services provided in a client's home by licensed professionals, designed to help individuals recover from illness or injury, manage chronic conditions, or live independently.

• Includes skilled nursing, physical therapy, occupational therapy, and home health aide services.
• Requires a physician's order and client's home-bound status (for Medicare).
• Focuses on continuity of care and preventing rehospitalization.

Memory trick: Home care holds the whole picture for heart care.

Management of severe epistaxis (nosebleed) unresponsive to direct pressure involves more advanced interventions such as nasal packing or cauterization to stop persistent bleeding.

• Initial management is direct pressure for 10-15 minutes, leaning forward.
• Persistent bleeding, especially posterior, requires medical intervention.
• Aspiration risk is a concern if blood drains posteriorly.

Memory trick: Pack the nose when pressure's failed, a bloody crisis now assailed!

Sacubitril/valsartan, an ARNI, effectively treats heart failure but carries a significant risk of angioedema due to increased bradykinin levels.

• Combines a neprilysin inhibitor (sacubitril) and an ARB (valsartan).
• Increases natriuretic peptides while blocking angiotensin II.
• Contraindicated with ACE inhibitors and within 36 hours of discontinuing an ACE inhibitor due to angioedema risk.

Memory trick: Angioedema's Alarm, Avoid ACE's Arm.

Clients with CVA are at high risk for aspiration due to neurological deficits affecting swallowing and airway protection. Initial interventions focus on positioning and careful assessment.

• Neurological deficits post-CVA impair swallowing and gag reflex.
• Elevating the head of the bed is a primary non-pharmacological intervention.
• A swallow screen should be performed before oral intake.

Memory trick: Head of bed up high, keeps the lungs dry!

Cerebral Perfusion Pressure (CPP) is the net pressure gradient causing cerebral blood flow to the brain, calculated as Mean Arterial Pressure (MAP) minus Intracranial Pressure (ICP).

• Formula: CPP = MAP - ICP.
• Normal CPP is 70-100 mmHg; desired for TBI is often 60-70 mmHg.
• Maintaining adequate CPP is vital to prevent cerebral ischemia.

Memory trick: MAP minus ICP, gives the brain its blood, you see!

Priority nursing care for a suspected ruptured cerebral aneurysm (subarachnoid hemorrhage) focuses on preventing rebleeding, managing intracranial pressure, and reducing cerebral vasospasm.

• Symptoms include 'worst headache of life,' nuchal rigidity, photophobia.
• A quiet, calm environment is crucial to minimize stimuli and prevent ICP spikes.
• Strict blood pressure control and seizure precautions are also vital.

Memory trick: Quiet brain, low light, prevents the aneurysm's bite!

Bleeding from esophageal varices is a life-threatening complication of portal hypertension, requiring rapid intervention to reduce portal pressure and control hemorrhage.

• Octreotide is the first-line pharmacologic treatment for acute variceal bleeding.
• It works by decreasing splanchnic blood flow.
• Endoscopic interventions (banding, sclerotherapy) are also crucial.

Memory trick: Octreotide Obstructs Outflow.

Competent adult clients have the legal and ethical right to refuse any medical treatment, even if that refusal could lead to serious harm or death.

• Applies to alert and oriented adults.
• Healthcare providers must respect this decision.
• Requires thorough documentation and communication to the healthcare team.

Memory trick: Refusal means report, right, and respect.

The process by which healthcare providers and clients are cooperatively involved in ongoing healthcare management toward the shared goal of high-quality, cost-effective medical care.

• Ensures seamless transition between care settings.
• Reduces fragmentation of care and potential for errors.
• Requires effective communication and information sharing among providers.

Memory trick: Medications are the lifeline to a new home.

The legal and ethical process where a client gives voluntary permission for a medical procedure or treatment after receiving and understanding all necessary information, including risks, benefits, and alternatives.

• Physician is responsible for providing comprehensive information.
• LPN's role is to witness the signature and ensure client appears to understand.
• If client has questions, LPN must notify RN/physician for further clarification.

Memory trick: Consent is clear understanding, not just a signature.

The ethical principle that respects an individual's right to make their own decisions about their healthcare, free from coercion or undue influence.

• Central to informed consent and end-of-life care.
• Requires clients to be competent to make decisions.
• Nurses advocate for client's right to self-determination.

Memory trick: Autonomy's core is choice; clarify, connect, keep quiet.

Pulmonary embolism is a blockage in one of the pulmonary arteries in the lungs. Initial management focuses on improving oxygenation and stabilizing the client.

• Symptoms often include sudden dyspnea, pleuritic chest pain, and hypoxemia.
• Risk factors include prolonged immobility, surgery, and certain medical conditions.
• Immediate interventions prioritize oxygenation and client comfort.

Memory trick: OXYGEN First for PE, then Doctor's orders decree!

Albuterol is a bronchodilator used to relieve acute asthma symptoms. Its primary therapeutic effect is to open airways, leading to improved breathing and oxygenation.

• It's a short-acting beta-2 agonist (SABA).
• Relieves bronchospasm.
• Desired effects: decreased wheezing, improved breath sounds, increased SpO2.

Memory trick: Albuterol's breath, brings oxygen's wealth!