NHRA Nurse Exam flashcards

32 cards. Read the term and the definition here. The deck at the top of this page is optional.

ABCDE assessment sequence

A structured priority order for assessment: Airway, Breathing, Circulation, Disability (neurologic status), and Exposure. Reassess after every intervention because airway and breathing threats supersede all other findings.

Shock index

Shock index equals heart rate divided by systolic blood pressure. A value above roughly 0.9 suggests occult hypoperfusion and early compensated shock even when blood pressure still appears normal.

Cushing triad

Hypertension with widened pulse pressure, bradycardia, and irregular respirations. This triad indicates rising intracranial pressure and impending herniation and is a neurologic emergency requiring immediate escalation.

Orthostatic hypotension criteria

A drop of at least 20 mmHg systolic or 10 mmHg diastolic within three minutes of standing from supine. It increases fall risk and may reflect hypovolemia or medication effect.

AVPU consciousness scale

A quick level-of-consciousness screen: Alert, responds to Voice, responds to Pain, Unresponsive. Any decline from baseline warrants reassessment and consideration of glucose measurement and airway protection.

Oxygen delivery device ranges

Nasal cannula delivers roughly 24-44% at 1-6 L/min; simple mask 35-55% at 5-10 L/min; nonrebreather up to 95% at 10-15 L/min. Venturi masks provide precise fixed FiO2.

Pressure injury staging

Stage 1 is nonblanchable erythema; stage 2 partial-thickness loss; stage 3 full-thickness loss; stage 4 exposed bone, tendon, or muscle. Unstageable injuries are obscured by eschar or slough.

Adult urine output target

Adequate adult urine output is approximately 0.5 to 1 mL/kg/h. Lower output suggests hypovolemia, renal injury, or obstruction and should prompt fluid and perfusion reassessment.

Chest tube drainage red flags

Report more than 100 mL/h of bright red drainage, sudden cessation with deterioration, or absent tidaling. Never clamp a chest tube without a specific provider order because tension pneumothorax may develop.

High-quality CPR parameters

Adult compressions at 100-120 per minute, depth 5-6 cm, with full chest recoil. Interruptions should stay under 10 seconds and the compression-to-ventilation ratio is 30:2 for one rescuer.

Blood transfusion reaction action

For fever, chills, flank pain, or dark urine, stop the transfusion immediately, keep the IV line patent with normal saline, notify the provider, and return the bag and tubing.

Standard precautions

Infection control applied to every patient regardless of diagnosis: hand hygiene plus gloves, gown, mask, and eye protection based on anticipated exposure to blood or body fluids.

Airborne precautions

Required for tuberculosis, measles, and varicella. Use an N95 or higher respirator and a negative-pressure room; a surgical mask is insufficient for these organisms.

C. difficile hand hygiene

Alcohol-based rub does not reliably kill C. difficile spores, so soap-and-water handwashing is required. Contact precautions with gown and gloves also apply for the duration of diarrhea.

Needlestick immediate actions

Wash the site immediately with soap and water without squeezing or scrubbing, report the exposure, and begin post-exposure evaluation. Timing of prophylaxis matters for HIV and hepatitis B.

Universal protocol elements

Before an invasive procedure, verify the correct patient, procedure, and site; mark the site when indicated; and conduct a time-out with the team immediately before starting.

Six rights of medication

Right patient, right drug, right dose, right route, right time, and right documentation. Many organizations add right reason and right to refuse or response.

Digoxin toxicity signs

Early signs include nausea, anorexia, visual halos or yellow-green vision, and bradycardia or new arrhythmia. Therapeutic levels are roughly 0.5-2 ng/mL and are checked with electrolytes and renal function.

Warfarin monitoring and reversal

Warfarin is monitored by INR, usually targeted at 2-3 for most indications. Vitamin K is the antidote, with prothrombin complex concentrate added for major bleeding.

Heparin monitoring and antidote

Unfractionated heparin is monitored by aPTT or anti-Xa level. Protamine sulfate reverses heparin, and platelet counts are watched for heparin-induced thrombocytopenia.

Opioid overdose antidote

Naloxone reverses opioid-induced respiratory depression and sedation. Because its duration is shorter than most opioids, repeat dosing and continued respiratory monitoring are required.

Insulin onset categories

Rapid-acting lispro and aspart act in 10-15 minutes; regular insulin in 30-60 minutes; NPH in 1-2 hours; glargine in 1-2 hours with no peak. Timing must match meals to prevent hypoglycemia.

Informed consent elements

Valid consent requires capacity, disclosure of risks, benefits, and alternatives, voluntariness, and patient authorization. The provider obtains consent; the nurse may witness and verify understanding.

Negligence four elements

A negligence claim requires duty owed to the patient, breach of that duty, causation linking breach to injury, and actual damages. All four elements must be established.

Nurse delegation limits

Unlicensed assistive personnel may perform delegated tasks but cannot perform nursing assessment, clinical judgment, teaching, or evaluation. Delegation requires the right task, circumstance, person, and supervision.

Assault versus battery

Assault is the threat of harmful or offensive contact; battery is actual unauthorized touching. Forcing care or applying restraints without proper order and justification may constitute battery.

Ethical principles in nursing

Autonomy respects self-determination, beneficence promotes good, nonmaleficence avoids harm, justice ensures fairness, and fidelity means keeping commitments. These guide resolution of clinical dilemmas.

SBAR handoff

A structured communication format: Situation, Background, Assessment, Recommendation. It is used for provider calls and shift reports to reduce omissions and clarify the requested action.

I-PASS handoff

A handoff framework: Illness severity, Patient summary, Action list, Situation awareness and contingency planning, and Synthesis by the receiver. The receiver restates the plan to confirm understanding.

Teach-back method

The clinician asks the patient to explain the plan or instructions in their own words. This confirms comprehension and identifies gaps better than asking whether the patient understands.

Closed-loop communication

The sender states a message, the receiver repeats it back, and the sender confirms accuracy. This technique reduces errors during critical events and verbal order transmission.

Late entry documentation

A late entry is labeled as late, dated and timed with the actual entry time, and states why it was delayed. It never alters or obscures an earlier note in the record.