NCLEX-RN flashcards

Increased pressure within a muscle compartment compromises perfusion, causing ischemia; it is a surgical emergency.

• 6 P's: Pain, Pallor, Paresthesia, Pulselessness, Poikilothermia, Paralysis
• Pain out of proportion to injury, unrelieved by opioids, is earliest sign
• Pulselessness is a late finding, do not wait for it
• Requires urgent fasciotomy or cast removal

Memory trick: 6 P's: Pain unrelieved is the first red flag

Warfarin therapy is monitored using INR, with a typical therapeutic target of 2-3 for most indications; vitamin K is the antidote for excessive anticoagulation.

• Therapeutic INR for AFib/DVT is usually 2-3
• Vitamin K (phytonadione) reverses warfarin effect
• INR >5 without bleeding often managed by holding dose ± oral vitamin K

Memory trick: 'Vitamin K Kicks warfarin back down'

Fluid shift and hypotension that can occur after rapid removal of large volumes of ascitic fluid.

• Monitor vital signs closely during and after the procedure
• Signs: hypotension, tachycardia, dizziness
• Treatment: supine positioning, IV fluid/albumin replacement, notify provider

Memory trick: 'Big fluid out, big fluid shift in' — hypovolemia after paracentesis.

Serum potassium below 3.5 mEq/L, often from GI losses, diuretics, or shifting into cells, causing muscle weakness and cardiac dysrhythmias.

• ECG: flattened T waves, prominent U waves, ST depression
• Causes: diarrhea, vomiting, diuretics, insulin administration
• Risk: paralytic ileus and life-threatening dysrhythmias

Memory trick: Low K = Ugly U waves and lazy bowels

Ventilator strategy using low tidal volumes and adequate PEEP to minimize further lung injury in ARDS.

• Tidal volume target ~6 mL/kg predicted body weight
• PEEP keeps alveoli open, improves oxygenation
• Permissive hypercapnia is acceptable trade-off
• Goal is to reduce ventilator-induced lung injury

Memory trick: Low and Slow protects the alveoli

Bleeding after percutaneous liver biopsy can cause referred right shoulder pain from diaphragmatic irritation along with signs of hypovolemic shock.

• Client positioned on right side post-biopsy to tamponade the puncture site
• Referred right shoulder pain signals diaphragmatic irritation from bleeding
• Falling BP and rising HR indicate hemorrhagic shock requiring urgent notification

Memory trick: Shoulder pain after liver biopsy = blood, not bruise

Competent adults have the legal right to refuse any medical treatment, even life-sustaining care, after being informed of the risks of refusal.

• Right to refuse is protected even for life-threatening conditions if client is competent
• Nurse must document informed refusal and notify provider
• Coercion or forcing treatment is battery and a violation of client rights

Memory trick: Competent = the client's choice is final

A relaxation technique in which the client visualizes calming, peaceful scenes to reduce the perception of pain and anxiety.

• Engages the parasympathetic nervous system to promote relaxation
• Can be used alone or with other non-pharmacologic methods
• Effective for chronic pain, procedural pain, and anxiety

Memory trick: Picture peace, ease the pain — imagery calms the brain.

Loss of gastric hydrochloric acid through NG suction or vomiting leads to metabolic alkalosis, with the lungs compensating by hypoventilating to retain CO2.

• ROME: Respiratory Opposite, Metabolic Equal
• NG suction/vomiting causes H+ loss, raising HCO3 and pH
• Partial compensation exists when pH remains abnormal despite CO2 changes

Memory trick: ROME: pH & HCO3 move together for metabolic

A progressive accumulation of air in the pleural space that shifts the mediastinum and compresses the heart and great vessels, causing obstructive shock.

• Signs: absent breath sounds, tracheal deviation away from affected side, JVD, hypotension
• Treatment: emergency needle decompression followed by chest tube insertion
• Untreated, it rapidly progresses to cardiac arrest

Memory trick: Trachea Tips Away, Treat right away with a needle

Assessment of the amount of formula/fluid remaining in the stomach during enteral feeding, used to evaluate gastric emptying and aspiration risk.

• GRV greater than 500 mL is generally considered high and warrants holding the feeding
• Reassess GRV per protocol (often after 1 hour) before resuming
• Elevated GRV may indicate delayed gastric emptying or intolerance

Memory trick: Over 500? Hold and check again before you feed.

Having a client sit at the edge of the bed with legs dangling before standing allows time for cardiovascular compensation, reducing orthostatic hypotension risk during first ambulation.

• Prevents sudden BP drop on standing
• Assess for dizziness before full standing
• Early ambulation prevents DVT, pneumonia, ileus

Memory trick: "Dangle before you dare to stand."

A life-threatening exacerbation of adrenal insufficiency causing severe hypotension, hyponatremia, hyperkalemia, and hypoglycemia, often triggered by abrupt steroid withdrawal or stress.

• Triggered by infection, stress, or abrupt corticosteroid discontinuation
• Treatment: IV hydrocortisone + isotonic fluids + glucose as needed
• Untreated leads to vascular collapse and death

Memory trick: Stop steroids suddenly = Shock strikes suddenly

A life-threatening syndrome in spinal cord injury above T6 caused by an unchecked sympathetic response to a noxious stimulus below the injury level, producing severe hypertension and bradycardia.

• Most common trigger: bladder distention (kinked catheter, UTI)
• First action: identify and remove the stimulus, sit client upright
• Untreated can cause stroke, seizure, or death

Memory trick: Full bladder, blown-up blood pressure—empty it first

LPNs care for stable clients with predictable outcomes, performing tasks such as reinforcing teaching, administering routine meds, and providing established care under RN supervision.

• LPNs cannot perform initial assessments or admission histories
• LPNs cannot administer blood products or IV push medications in most states
• Stable, chronic, predictable clients are appropriate LPN assignments

Memory trick: LPN = stable, LPN reinforces, RN initiates

Sepsis progresses to septic shock when infection causes persistent hypotension requiring vasopressors despite fluid resuscitation, along with organ dysfunction and altered mentation.

• qSOFA criteria: altered mentation, RR ≥22, SBP ≤100 mmHg
• Hypotension signals hemodynamic compromise requiring urgent fluids/vasopressors
• Early recognition and antibiotics/fluids within the first hour improve survival

Memory trick: Low BP with infection = shock is knocking

Serum potassium above 5.0 mEq/L that can cause life-threatening cardiac dysrhythmias.

• Normal K+ = 3.5–5.0 mEq/L
• ECG changes: peaked T waves, widened QRS, flattened P waves
• Treated with calcium gluconate, insulin/glucose, kayexalate, dialysis

Memory trick: 'Peaked T, call the MD' — hyperkalemia peaks the heart's rhythm.

Nurses have an ethical and legal obligation to report suspected impairment (e.g., alcohol, drugs) in a colleague to a supervisor immediately to protect client safety.

• Client safety is the priority, not workplace loyalty
• Reporting must go through proper channels (supervisor, manager)
• State boards often have peer assistance/diversion programs for impaired nurses

Memory trick: See it, report it—don't cover it

A technique used to turn a client as a single unit while maintaining spinal alignment, typically after spinal surgery or injury.

• Requires 2-3 staff members for proper support
• Keeps head, shoulders, and hips aligned during the turn
• Prevents twisting or flexion of the spinal column

Memory trick: Log stays straight — so does the spine when you roll it.

Battery is intentional, unauthorized physical contact with a client, such as performing a procedure without valid informed consent.

• Requires actual physical contact without consent
• Differs from assault, which is the threat of contact
• Informed consent must be obtained before any procedure
• Proceeding despite client confusion or lack of understanding is battery

Memory trick: No consent, no contact—touching without 'yes' is battery.

Perineal care should move from the urinary meatus (clean) toward the rectum (dirty), using a new area of cloth/wipe for each stroke to prevent catheter-associated urinary tract infection.

• Front-to-back / clean-to-dirty direction
• New wipe or cloth surface per stroke
• Reduces risk of catheter-associated UTI (CAUTI)

Memory trick: "Clean to dirty, never go backward."

False imprisonment is the unjustified restriction of a client's freedom of movement without a proper order or legitimate safety indication, such as restraining an alert, oriented client for staff convenience.

• Restraints require a physician's order and documented justification
• Restraining a competent client without cause is false imprisonment
• Different from battery (unauthorized touching) and assault (threat of harm)
• Least restrictive alternatives must be tried first

Memory trick: No order, no cause—restraint becomes a cage.

Nurses are legally required to report suspected child, elder, or domestic abuse to appropriate authorities, regardless of parental consent.

• Reporting is mandatory, not optional, for nurses
• Document objective findings without accusation
• Failure to report can result in legal liability
• Investigation is done by protective services, not the nurse

Memory trick: See suspicion, send a report—don't play detective.

Tasks requiring clinical judgment, assessment, or correlation with unstable conditions cannot be delegated to UAP, even if the task itself (like glucose checks) is routine.

• UAPs can perform data collection on stable clients
• RNs must retain tasks requiring assessment or judgment
• Unstable clients (e.g., DKA, insulin drips) need RN oversight
• The five rights of delegation include right task and right circumstance

Memory trick: Stable checks to UAP, unstable stays with RN's cap.

Entry of air into the venous system, often during central line insertion or removal, causing a churning heart murmur, chest pain, and hypoxia.

• Occurs during central line insertion/removal if the site is not occluded
• Position: left lateral Trendelenburg's traps air in right atrium
• Classic sign: mill-wheel/churning murmur
• Prevent by having client perform Valsalva during catheter removal

Memory trick: 'Left side down, head down, air stays trapped in the drum (right atrium).'

Excess antidiuretic hormone causes water retention, dilutional hyponatremia, and concentrated urine without edema.

• Causes euvolemic hyponatremia
• Urine is concentrated despite low serum sodium
• Weight gain without edema is classic
• Treatment includes fluid restriction and hypertonic saline for severe cases

Memory trick: SIADH Soaks the body but Skin stays normal

A positional headache caused by cerebrospinal fluid leakage at the puncture site, worse when upright and relieved when supine.

• Caused by low CSF pressure from leakage at puncture site
• Managed with flat positioning, hydration, and caffeine
• Persistent headache may require an epidural blood patch

Memory trick: Lie low to say no to LP headache

A set of behavioral practices that promote consistent, restorative sleep.

• Maintain a consistent sleep-wake schedule daily
• Avoid caffeine, nicotine, and heavy exercise close to bedtime
• Reserve the bed for sleep only, avoid screens in bed

Memory trick: Same clock, same rock — steady sleep schedule builds a steady body clock.

The earliest stage of shock in which the body activates sympathetic responses (tachycardia, vasoconstriction) to maintain perfusion while blood pressure remains normal.

• Tachycardia is the earliest sign of shock
• BP stays normal until compensatory mechanisms fail
• Progresses to decompensated then irreversible shock if untreated

Memory trick: Heart races first, pressure falls last

When a client has limited English proficiency, a qualified medical interpreter—not a family member—should be used to ensure accurate communication and valid informed consent.

• Family members may introduce bias or omit sensitive information
• Use of professional interpreters is a client right and legal requirement
• Nurses act as advocates to ensure true understanding before consent

Memory trick: Professional, not personal — call the interpreter, not the relative.

Acid-base imbalance from CO2 retention, causing decreased pH and elevated PaCO2.

• Normal pH: 7.35–7.45
• Normal PaCO2: 35–45 mmHg
• Normal HCO3: 22–26 mEq/L
• Uncompensated = only one value abnormal besides pH

Memory trick: ROME: Respiratory Opposite, Metabolic Equal (pH & CO2 move opposite in respiratory).

A complication of long bone or pelvic fractures where fat globules enter the circulation and lodge in pulmonary and cerebral capillaries, causing respiratory distress, altered mental status, and petechiae.

• Onset typically 24–72 hours after fracture
• Classic triad: hypoxemia, neurologic changes, petechial rash on chest/neck/axillae
• Management is supportive: oxygen, fracture stabilization, and monitoring for ARDS

Memory trick: Break a big bone, fat roams, rash and confusion come home

A dangerous adverse effect of opioids in which respiratory rate falls (often <10-12/min) with sedation, requiring immediate intervention and naloxone reversal.

• Naloxone is the opioid antagonist antidote
• Assess sedation level and RR before each PCA dose
• Stop opioid infusion first, then administer naloxone per protocol

Memory trick: 'RR under 10, stop and give Narcan'

For conscious clients with blood glucose <70 mg/dL, give 15 g fast-acting carbohydrate, recheck glucose in 15 minutes, and repeat if still low.

• 15 g carb = 4 oz juice, 3-4 glucose tablets, or 1 tbsp honey
• Recheck glucose 15 min after treatment
• Glucagon IM/IN reserved for unconscious clients

Memory trick: '15-15-15': 15 g carb, wait 15 min, check again

Toxic effect of digoxin causing GI, visual, and cardiac symptoms, worsened by hypokalemia.

• Therapeutic digoxin level: 0.5–2.0 ng/mL
• Classic signs: nausea, vomiting, visual halos, bradycardia
• Hypokalemia increases risk of toxicity

Memory trick: 'Low K, high risk' — low potassium raises digoxin danger.

A valid advance directive or DNR order documents the client's wishes and legally overrides family requests when the client cannot make decisions for themselves.

• Advance directives must be honored even if family disagrees
• DNR orders must be verified/documented by the healthcare team
• Client autonomy is a core ethical principle guiding end-of-life decisions

Memory trick: The paper speaks for the patient, not the family

A deficiency of antidiuretic hormone, often after pituitary surgery or head trauma, causing excretion of large volumes of dilute urine and resulting hypernatremia/dehydration.

• Hallmarks: polyuria (>200 mL/hr), low urine specific gravity (<1.005), hypernatremia
• Common cause: pituitary/hypothalamic surgery or trauma
• Treatment: desmopressin (DDAVP) and fluid replacement

Memory trick: DI = Dry Inside (dilute urine, dehydration); SIADH = Soaked Inside

When a nurse is floated to an unfamiliar unit, assignments should match the nurse's competencies — typically the most stable clients with the lowest acuity and complexity.

• Floated nurses should receive orientation to unit-specific equipment/protocols
• Assign stable, low-acuity clients to floated staff
• Specialized care (chemo, epidurals, critical respiratory needs) should go to unit-based staff

Memory trick: Float to the stable, not the unstable.

Internal bleeding after surgery can occur even with a dry external dressing, presenting as tachycardia, hypotension, pallor, and diaphoresis.

• Tachycardia is an early compensatory sign of blood loss
• Hypotension is often a late sign of shock
• A dry dressing does not exclude internal hemorrhage

Memory trick: Cold, Clammy, Collapse—Call!

Dehiscence is separation of wound edges; evisceration occurs when abdominal organs protrude through the incision, constituting a surgical emergency.

• Sudden 'give way' sensation with visible bowel protrusion signals evisceration
• Cover exposed organs with sterile saline-soaked gauze immediately
• Position client supine with knees bent to reduce abdominal tension and notify surgeon stat

Memory trick: Wet gauze, bent knees, call the team

Preventive hygiene practices for clients with diabetes to reduce risk of ulceration, infection, and amputation due to neuropathy and poor circulation.

• Inspect feet daily for cuts, blisters, or redness
• Avoid soaking feet; wash and dry thoroughly, especially between toes
• Wear properly fitted, closed-toe shoes and avoid walking barefoot

Memory trick: Dry, not soggy — soaking makes diabetic skin boggy.

IV contrast can precipitate acute kidney injury, which combined with metformin increases lactic acidosis risk.

• Hold metformin 48 hours before and after contrast studies
• Check renal function (creatinine/eGFR) before resuming
• Contrast-induced nephropathy risk higher in CKD, diabetes, dehydration

Memory trick: 'Metformin + dye = lactic acid alert' — hold 48 hours.

Tricyclic antidepressant overdose blocks cardiac sodium channels, causing widened QRS and arrhythmias treated with sodium bicarbonate.

• Widened QRS >100 ms indicates significant toxicity
• Sodium bicarbonate is the antidote of choice
• Also causes anticholinergic effects and seizures
• Activated charcoal used only for early GI decontamination

Memory trick: Bicarb Blocks the Blockade in TCA toxicity

Loss of gastric acid (HCl) through vomiting or NG suction raises serum bicarbonate and pH, causing metabolic alkalosis.

• Common causes: vomiting, NG suction, diuretics, antacid overuse
• Often accompanied by hypokalemia and hypochloremia
• pH >7.45, HCO3- >26 mEq/L
• Treatment addresses underlying cause and replaces electrolytes

Memory trick: Vomiting Voids acid, raising pH and bicarb

A histamine-release reaction to rapid vancomycin infusion causing flushing, pruritus, and rash on the face, neck, and upper trunk—not a true drug allergy.

• Caused by rapid infusion, not IgE-mediated allergy
• Managed by slowing the infusion rate
• Vancomycin should typically infuse over at least 60 minutes

Memory trick: 'Red Man = Ran too fast' — slow it down

Accidental removal or injury of parathyroid glands during thyroidectomy causes hypocalcemia, presenting as perioral tingling, muscle twitching (Chvostek/Trousseau signs), and risk of laryngospasm.

• Signs: perioral/finger tingling, muscle cramps, Chvostek's/Trousseau's sign
• Can progress to laryngospasm and airway obstruction—emergency
• Keep IV calcium gluconate at bedside for postop thyroidectomy clients

Memory trick: Tingling lips post-thyroid = airway alarm

Altering food and liquid consistency to reduce aspiration risk in clients with impaired swallowing.

• Thickened liquids (nectar, honey, pudding) slow transit time
• Chin-tuck position reduces aspiration risk
• Monitor for coughing, throat clearing, or wet voice during meals

Memory trick: Thick and slow keeps liquids where they need to go.

Excess serum magnesium causes loss of deep tendon reflexes, respiratory depression, and decreased urine output; calcium gluconate is the antidote.

• Therapeutic magnesium level for preeclampsia: 4-7 mEq/L
• Toxicity signs: absent DTRs, RR <12/min, oliguria, decreased LOC
• Antidote: calcium gluconate IV

Memory trick: 'No reflex, no breath, no pee — stop the Mag and call for Ca'

A law that protects healthcare providers who voluntarily give emergency care outside of their employment from liability, provided care is reasonable and not grossly negligent.

• Applies to voluntary, unpaid emergency assistance
• Does not protect gross negligence or willful misconduct
• Encourages bystanders to help without fear of lawsuits
• Varies slightly by state but core protection is similar

Memory trick: Good faith at the scene keeps you clean.

Protected health information cannot be disclosed to family members without the client's consent unless the client is incapacitated and disclosure serves their immediate best interest.

• Confidentiality applies even to close relatives
• Client authorization is required for disclosure
• Nurses can offer to relay messages without breaching privacy
• Exceptions exist for incapacitated clients needing emergency decisions

Memory trick: Family isn't a free pass to the file.

When a nurse witnesses a client's signature on a consent form, the nurse confirms voluntariness and apparent competence, not that teaching or disclosure occurred.

• Disclosure of risks/benefits is the physician's duty
• Witnessing verifies signature is voluntary
• Nurse should notify provider if client seems confused or uninformed
• Nurses commonly serve as witnesses, not only physicians

Memory trick: Witnessing is watching the pen, not repeating the pitch.

Low serum potassium increases digoxin binding to cardiac cells, potentiating toxic effects even at normal digoxin levels.

• Signs: nausea, visual halos, bradycardia, dysrhythmias
• Never give IV potassium by push—infuse slowly and diluted
• Loop diuretics like furosemide cause potassium loss increasing toxicity risk

Memory trick: Low K = digoxin gets stronger and more toxic

A severe, rapid-onset allergic reaction causing airway swelling, bronchospasm, and vasodilation leading to shock; epinephrine IM is first-line treatment.

• Stop the causative agent immediately
• Epinephrine 0.3-0.5 mg IM is first-line treatment
• Antihistamines and steroids are adjuncts, not first-line

Memory trick: Stop it, then shoot it—stop the drug, give epinephrine

Diabetic ketoacidosis treatment sequence is fluids, then insulin, then potassium replacement as needed.

• Isotonic saline corrects volume deficit first
• Insulin infusion stops ketogenesis and lowers glucose
• Monitor potassium closely as insulin drives K+ into cells
• Bicarbonate reserved for severe acidosis only

Memory trick: Fluids First, then Fix with Insulin

Gravity IV flow rate (gtt/min) = (Volume in mL x Drop factor in gtt/mL) / Time in minutes.

• Convert total infusion time to minutes or use hourly rate x drop factor / 60
• Always round drops per minute to the nearest whole number
• Drop factor varies by tubing: macrodrip 10-20 gtt/mL, microdrip 60 gtt/mL

Memory trick: 'Volume times drop factor, divide by the minutes'

Compensation is classified as none, partial, or full based on whether pH has returned to normal range despite abnormal PaCO2/HCO3-.

• Normal pH range: 7.35-7.45
• Partial compensation: pH abnormal, but opposite system shifted toward normal
• Full compensation: pH normalized, both PaCO2 and HCO3- abnormal
• Uncompensated: only one value abnormal, pH markedly abnormal

Memory trick: ROME: Respiratory Opposite, Metabolic Equal

The volume of urine remaining in the bladder after voiding, used to assess urinary retention.

• Normal PVR is less than 50-100 mL
• PVR greater than 200 mL generally requires catheterization
• Retention increases risk for UTI and bladder/kidney damage

Memory trick: Two hundred is the line — cross it and it's cath time.

Application of temperature-based non-pharmacologic pain relief; cold is used for acute injury/inflammation, heat is used for chronic pain/muscle relaxation.

• Cold therapy: use within first 24-48 hours of acute injury, vasoconstriction reduces swelling
• Heat therapy: use for chronic pain or muscle stiffness, promotes vasodilation and relaxation
• Always wrap ice packs in a towel to prevent frostbite/skin damage

Memory trick: Ice it right after — heat comes later.

Adequate dietary fiber (25-30 g/day) combined with sufficient fluid intake (2-3 L/day) softens stool and stimulates peristalsis to prevent constipation.

• Increase fiber gradually to avoid gas/bloating
• Fluid must accompany fiber intake
• Physical activity also promotes bowel motility

Memory trick: "Fiber needs fluid, or it turns to concrete."

A life-threatening hypermetabolic reaction to certain anesthetics/succinylcholine causing muscle rigidity, hyperthermia, and tachycardia.

• Early sign: rising end-tidal CO2 despite stable ventilation
• Presents with muscle rigidity, tachycardia, hyperthermia, tachypnea
• Treatment: stop triggering agent, give dantrolene sodium, cool client

Memory trick: 'Rigid + rising CO2 = Dantrolene to the rescue.'