NCLEX-PN® Examination flashcards

Physical abilities involving large muscle movements that a child typically achieves by 24 months of age.

• Running fairly well.
• Kicking a ball forward.
• Walking up and down stairs holding on.

Memory trick: Two-year-olds Take Steps Steadily.

The process of determining the correct volume or quantity of medication to administer based on the prescribed dose and available concentration.

• Formula: (Desired Dose / Available Concentration) x Volume.
• Ensure units are consistent before calculation.
• Double-check calculations to prevent medication errors.

Memory trick: Think 'D/H x V': Doctors Have Values, which helps you get the right dose.

Signs of acute respiratory distress include changes in mental status, increased work of breathing, and significant hypoxemia.

• Restlessness and confusion can indicate hypoxemia or hypercapnia.
• Increased respiratory rate and effort are compensatory mechanisms.
• Requires immediate intervention and escalation of care.

Memory trick: When breathing goes bad, think 'RED ALERT!' for rapid escalation.

Initial diagnostic tests for suspected kidney stones typically include urinalysis to check for blood and infection, and renal ultrasound to visualize stones and assess for obstruction.

• Urinalysis detects hematuria and signs of infection.
• Renal ultrasound visualizes stones and hydronephrosis.
• CT scan is more definitive but often follows initial tests.

Memory trick: Kidney Stone K.O.: Know Organ, Observe Output

The process of emotional and physical reactions to loss, heavily influenced by an individual's spiritual and cultural background, impacting how grief is expressed and managed.

• Grief is a universal human experience but expressed differently across cultures.
• Spiritual beliefs often provide comfort or meaning during loss.
• Cultural rituals for mourning can significantly affect the grieving process.

Memory trick: Grief's path, spirit's guide, culture's stride.

The client's right to make independent choices about their healthcare, provided they have the capacity to understand information and consequences, even if family disagrees.

• Capacity is key for autonomy.
• Advance directives guide decisions when capacity is lost.
• Healthcare team must respect client's informed choices.

Memory trick: Autonomy's Alert, Report to RN, Resolve

An air embolism is a serious complication of central venous access, presenting with sudden dyspnea, chest pain, tachycardia, hypotension, and decreased breath sounds, often with a 'mill wheel' murmur.

• Sudden onset of respiratory distress.
• Chest pain, tachycardia, hypotension.
• Can be prevented by proper line management (clamping, Valsalva).
• Immediate action: clamp line, Trendelenburg left side, O2.

Memory trick: PICC Problems: Pushed Air, Infected, Clotted, Collapsed

Furosemide, a loop diuretic, primarily causes the excretion of potassium, leading to hypokalemia. Clients on furosemide require regular monitoring of potassium levels.

• Loop diuretics inhibit reabsorption in the loop of Henle.
• Increases excretion of Na, Cl, K, and water.
• Hypokalemia is a common and serious side effect.

Memory trick: Furosemide's Flow: K+ Goes Low

Nurses prepare clients for cardiac catheterization by providing education, ensuring NPO status, and assessing for allergies.

• NPO status (typically 6-12 hours) is essential to prevent aspiration.
• Assess for allergies to iodine, shellfish, or contrast dye.
• Educate the client about sensations during the procedure (e.g., warmth from dye).

Memory trick: Before the heart journey, make sure the stomach is empty, like a pre-flight checklist for an airplane.

Safe storage of medications, particularly in locked cabinets, is crucial to prevent accidental poisoning in the home, especially for children and vulnerable adults.

• Locked storage is the most effective barrier.
• Child-resistant caps are a secondary measure.
• Keep medications in original containers.

Memory trick: Lock It Up, Don't Mess Up.

In hypovolemic shock, inadequate tissue perfusion leads to organ dysfunction. Severely decreased urine output (<0.5 mL/kg/hr) is a critical indicator of renal hypoperfusion and impending acute kidney injury, requiring immediate intervention.

• Low urine output signals renal hypoperfusion.
• Early detection prevents irreversible organ damage.
• Other signs: hypotension, tachycardia, altered mental status.

Memory trick: Vital Signs: Urine Output is the Ultimate Organ Damage Signal

For chronic conditions like hypertension, medications often require continuous use as prescribed, even when symptoms improve, to maintain therapeutic effects and prevent complications.

• Abrupt discontinuation can be dangerous.
• Clients should always consult their provider before changing dosage or stopping.
• Adherence is key to long-term management.

Memory trick: Don't Guess, Ask the Best (your prescriber).

Respiratory acidosis is characterized by a low pH and high PaCO2, often due to hypoventilation. Partial metabolic compensation occurs when the kidneys retain bicarbonate, raising HCO3, to buffer the acidosis.

• Low pH, high PaCO2 are primary indicators.
• High HCO3 indicates renal compensation.
• Common in COPD exacerbations due to impaired gas exchange.

Memory trick: ROMA: Respiratory Opposite, Metabolic Alike

Working effectively with other healthcare professionals to provide comprehensive and coordinated client care.

• Involves clear communication and mutual respect.
• Ensures holistic client management.
• Leverages diverse expertise for optimal outcomes.

Memory trick: Team Collaboration for Complex Pain

Immunizations administered shortly after birth to provide early protection against specific diseases.

• Hepatitis B (HepB) is the primary vaccine given at birth.
• It protects against a potentially life-threatening liver infection.
• Subsequent doses are required to complete the series.

Memory trick: Born with B, then later you'll see.

Enteral feeding bags and tubing are sterile when opened but can become colonized with bacteria over time. They must be changed regularly (typically every 24 hours) to minimize the risk of infection.

• Prevents bacterial contamination of formula.
• Reduces risk of gastrointestinal infection.
• Follow facility policy for specific hang times (usually 12-24 hours).

Memory trick: Don't let Old Bags become Germ Flags.

Specific limitations on food and fluid intake to manage symptoms and prevent exacerbations in clients with heart failure, primarily focusing on sodium and fluid.

• Low sodium diet is critical.
• Fluid restriction may be necessary.
• Requires careful reading of food labels.

Memory trick: Low Sodium, Label Logic, Less Swelling

Ascites can cause respiratory distress due to increased intra-abdominal pressure on the diaphragm. Elevating the head of the bed (semi-Fowler's or high-Fowler's) helps improve lung expansion and ease breathing.

• Increased abdominal girth compresses diaphragm.
• Leads to shortness of breath.
• Semi-Fowler's position improves lung expansion.
• Fluid restriction and diuretics are also key.

Memory trick: Ascites Airway Aid: Position Up, Fluid Down

Infiltration occurs when IV fluid leaks into the surrounding subcutaneous tissue instead of entering the vein. It presents as swelling, coolness, and pain at the insertion site.

• Immediate action is to stop the infusion and remove the catheter.
• Can cause discomfort and potential tissue damage.
• Often requires starting a new IV in a different location.

Memory trick: Stop the Drip, then Strip the Trip.

A condition characterized by abnormally low levels of potassium in the blood, typically below 3.5 mEq/L.

• Can cause cardiac dysrhythmias, muscle weakness, and fatigue.
• Often associated with diuretic use, vomiting, diarrhea, or inadequate dietary intake.
• Requires prompt medical intervention to prevent serious complications.

Memory trick: Electrolytes are like tiny charged wires; if potassium drops too low, the heart's circuit can short-circuit.

Physical activity that forces you to work against gravity, such as walking or running, which helps strengthen bones and prevent osteoporosis.

• Essential for bone density.
• Includes walking, jogging, dancing.
• Stimulates bone formation.

Memory trick: To strengthen bones, bear some weight, or osteoporosis will seal your fate.

Proper technique for ambulating with a cane when one side of the body is weaker, emphasizing holding the cane on the unaffected (stronger) side.

• Cane held on strong side.
• Advances with the weak leg.
• Provides wider base of support.

Memory trick: Strong side holds the cane, to support the weak one's pain.

Maintaining oral comfort and hygiene for clients who are NPO (nil per os) without allowing any oral intake of fluids or food.

• Use moist swabs or sponges.
• Do not allow swallowing of water.
• Relieves dry mouth and discomfort.

Memory trick: For NPO, moist swabs are the key, keeping mouths fresh, without breaking the 'no liquids' decree.

Proactive nursing interventions aimed at mitigating adverse effects of prolonged bed rest or limited movement, such as pressure injuries, DVT, and respiratory issues.

• Repositioning prevents pressure injuries.
• Early mobilization (if allowed) is key.
• Respiratory exercises prevent pneumonia.

Memory trick: Regular repositioning protects the skin's integrity, a vital defense against immobility's severity.

Specialized tools and equipment designed to compensate for motor impairments like tremors, facilitating daily activities such as eating.

• Weighted utensils help stabilize hands.
• Non-slip mats prevent dishes from moving.
• Promote independence and reduce aspiration risk.

Memory trick: Weighted utensils make feeding less daunting, steadying the hand's uncertain motion.