CPNRE / REx-PN flashcards

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

SBAR handoff

A structured communication tool: Situation, Background, Assessment, Recommendation. Used for any transfer of care to ensure complete and concise information.

Five rights of delegation

Right task, right circumstance, right person, right direction/communication, right supervision/evaluation. RN retains accountability for delegated tasks.

Prioritization ABC

Airway, Breathing, Circulation first; then Maslow's hierarchy (physiological before safety before psychosocial); acute and unstable conditions before chronic and stable.

Informed consent

Provider obtains consent; nurse witnesses and verifies client understanding, voluntariness, and competence. Client may refuse or withdraw consent at any time.

Standard precautions

Apply to all clients: hand hygiene, gloves, gown, mask, eye protection based on anticipated exposure to blood, body fluids, secretions, or excretions.

Airborne precautions

Used for TB, measles, varicella. Requires N95 respirator, negative-pressure room, and door closed. Client wears mask when transported.

Seizure precautions

Padded side rails, bed low, suction and oxygen at bedside, nothing in mouth during seizure, turn to side after to maintain airway.

Restraint use

Requires provider order, time-limited, least restrictive, frequent monitoring of circulation, skin, and needs. Never PRN, punitive, or for convenience.

Stages of change

Precontemplation, contemplation, preparation, action, maintenance, termination. Interventions should match the client's stage.

Newborn prophylaxis

Vitamin K injection at birth, erythromycin eye ointment, and hepatitis B vaccine within 24 hours of birth.

Teach-back method

Ask client to explain or demonstrate information in their own words. Confirms understanding and identifies gaps. Use plain language and limit to 3 key points.

Developmental milestones

Sits unsupported 6–8 months, walks 12–15 months, two-word phrases by 2 years. Use to screen for delays.

Therapeutic communication

Open-ended questions, reflection, silence, clarification. Avoid 'why' questions, false reassurance, and giving advice.

Suicide risk assessment

Directly ask about suicidal thoughts; assess plan, means, intent, and history. Remove means, never leave alone, and follow safety protocol.

Delirium vs dementia

Delirium is acute, fluctuating, with altered attention and consciousness. Dementia is chronic, progressive, with intact consciousness until late stages.

Alcohol withdrawal

Monitor with CIWA-Ar for tremors, tachycardia, hallucinations, seizures. Treat with benzodiazepines per protocol and provide supportive care.

Pressure injury prevention

Reposition every 2 hours, use Braden scale, manage moisture, provide nutrition with protein, vitamin C, and zinc. Inspect skin regularly.

Pain assessment tools

Numeric scale 0–10 for adults; Wong-Baker FACES for children; PAINAD for clients with dementia. Reassess after intervention.

Opioid side effects

Constipation (give stimulant laxative), respiratory depression (monitor RR and sedation), nausea (anti-emetic). Monitor for oversedation.

Urinary catheter care

Keep bag below bladder, empty every 8 hours, perform perineal care daily, and remove catheter as soon as possible to prevent CAUTI.

IV flow rate formula

gtt/min = (volume in mL × drop factor in gtt/mL) / time in minutes. Verify with pump when available.

Insulin onset times

Rapid-acting (lispro) onset 15 minutes; regular onset 30–60 minutes; NPH peak 4–12 hours; glargine peakless. Match meal timing to insulin.

Heparin and warfarin monitoring

Heparin: monitor aPTT; antidote protamine sulfate. Warfarin: monitor INR; antidote vitamin K. Both increase bleeding risk.

Digoxin precautions

Hold if apical heart rate <60 in adults. Monitor potassium; therapeutic level 0.5–2 ng/mL. Signs of toxicity: nausea, visual changes, arrhythmias.

Blood transfusion reactions

Stay with client during first 15 minutes at slow rate. If reaction occurs, stop transfusion, maintain IV access with normal saline, and notify provider.

Post-operative complications

Monitor for atelectasis (incentive spirometer), DVT (early ambulation, SCDs), infection (temperature, wound), and hemorrhage (vitals, dressing).

Hypoglycemia treatment

Blood glucose <70 mg/dL. Give 15 g fast-acting carbohydrate, recheck in 15 minutes. If unconscious, give glucagon or IV dextrose per protocol.

Pressure injury staging

Stage 1: intact skin with non-blanchable redness. Stage 2: partial-thickness loss. Stage 3: full-thickness loss. Stage 4: full-thickness to bone/tendon.

DVT prevention

Early ambulation, sequential compression devices, compression stockings, anticoagulants. Do not massage legs. Monitor for unilateral swelling, pain, warmth.

Shock signs

Tachycardia, hypotension, tachypnea, cool clammy skin, decreased urine output, altered mental status. Treat cause, give oxygen, fluids, vasopressors.

DKA management

Hyperglycemia, ketosis, metabolic acidosis, Kussmaul respirations. Treat with IV fluids, insulin drip, and potassium replacement. Monitor glucose and electrolytes.

COPD oxygen therapy

Use low-flow oxygen (1–2 L/min) to maintain SpO2 88–92%. Teach pursed-lip breathing and monitor for CO2 retention.