CMSRN flashcards

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

Sepsis bundle initial actions

Obtain cultures before antibiotics, give broad-spectrum antibiotics promptly, measure lactate, and begin 30 mL/kg crystalloid for hypotension or lactate ≥4 mmol/L per surviving sepsis guidance.

Pressure injury stage 1

Intact skin with a localized area of non-blanchable erythema indicates tissue damage and requires repositioning and offloading, not massage.

Hypoglycemia treatment rule

If conscious and able to swallow, give 15 g fast-acting carbohydrate, recheck glucose in 15 minutes, and repeat until glucose is above 70 mg/dL.

Fall risk post-op

After sedation or anesthesia, assist with first ambulation, keep call light within reach, and use bed alarm when indicated.

MASD vs pressure injury

Moisture-associated skin damage from urine, stool, or wound drainage often has irregular borders and spares pressure points; pressure injury occurs over bony prominences.

Restraint monitoring

While restrained, assess circulation, skin, and respiratory status at least every 15 minutes, and release and reposition every 2 hours per policy.

Postoperative atelectasis prevention

Encourage incentive spirometry, deep breathing, coughing, and early ambulation to expand alveoli and clear secretions after surgery.

Blood transfusion reaction first step

Stop the transfusion immediately, keep the IV line patent with normal saline, assess vital signs, and notify the provider and blood bank.

Teach-back method

Ask the patient to explain or demonstrate the teaching in their own words, correct misunderstandings, and re-teach until accurate.

Health literacy universal precautions

Use plain language, limit to three key points, use pictures, and confirm understanding with all patients regardless of education level.

Heart failure daily weights

Teach patients to weigh daily at the same time, on the same scale, and report a gain of 2-3 pounds overnight or 5 pounds in a week.

Warfarin teaching

Teach consistent vitamin K intake, avoiding new medications without checking, using a soft toothbrush, and reporting bleeding or dark stool.

Diabetes sick-day rules

Continue insulin, check glucose and ketones as directed, drink fluids, and call provider for persistent vomiting, high glucose, or dehydration signs.

Smoking cessation 5 A's

Ask about tobacco use, Advise quitting, Assess willingness, Assist with counseling or medication, and Arrange follow-up.

Motivational interviewing

Use open questions and reflective listening to explore ambivalence and support the patient's own reasons for behavior change.

Discharge medication teaching

Use a reconciled list, explain purpose and timing, and have the patient or caregiver demonstrate administration before discharge.

Five rights of delegation

Right task, circumstance, person, direction/communication, and supervision; delegate according to state nurse practice act and patient stability.

Incident report purpose

Document factual details of an unexpected event for quality improvement; do not place the report in the medical record.

Chain of command

Escalate concerns through charge nurse, nursing supervisor, and administrator when patient safety or scope issues are unresolved.

Informed consent nurse role

Verify the provider obtained consent, assess patient understanding, and witness signature; nurses do not obtain informed consent.

Just culture

Errors are examined systemically; reckless behavior is disciplined, and honest mistakes are supported with learning and process improvement.

Scope of practice

Each nurse practises within state law, facility policy, competence, and patient acuity; assignment does not authorize tasks outside scope.

Prioritization ABC

Airway, breathing, and circulation threats come before routine care; unstable patients are assessed and escalated first.

Professional boundary

Avoid personal relationships, gifts, or social media contact that exploit the nurse-patient power imbalance or compromise objectivity.

SBAR handoff

Situation, Background, Assessment, and Recommendation structure gives concise, complete information during clinical handoff or escalation.

Medication reconciliation

Compare all current medications with new orders at admission, transfer, and discharge to identify omissions, duplications, and interactions.

Case management role

Coordinates care, assesses resource needs, and arranges services to promote timely, safe transitions across settings.

Interdisciplinary team

Includes nursing, medicine, pharmacy, therapy, social work, and nutrition; shared goals require clear communication and role respect.

Discharge planning start

Begin at admission by assessing home support, function, equipment, transportation, and follow-up needs, then update the plan.

Conflict resolution

Address concerns privately, use I-statements, focus on patient goals, and escalate unresolved conflict through formal channels.

Family meeting purpose

Clarify goals of care, share information, and build consensus among patient, family, and team, documenting decisions.

Transitional care follow-up

Schedule timely follow-up, confirm medication access, and provide a contact number to reduce readmission risk after discharge.