NCLEX-PN flashcards

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

Five rights of delegation

Right task, right circumstance, right person, right direction/communication, and right supervision/evaluation. The delegating nurse retains accountability for the outcome and must confirm the UAP's competence first.

UAP delegation limits

Unlicensed assistive personnel may perform ADLs, ambulation, stable vital signs, and intake/output. They may not perform initial assessments, develop care plans, teach, evaluate outcomes, or administer medications.

SBAR handoff

A structured communication tool standing for Situation, Background, Assessment, and Recommendation. It is used at shift report and when calling a provider to reduce omissions and errors.

Incident report rules

Record objectively and factually what was observed, not opinions. Do not photocopy the report, and do not document in the client's progress notes that an incident report was filed.

Restraint monitoring intervals

Violent or self-destructive restraints require a provider face-to-face evaluation within 1 hour and assessment every 15 minutes; non-violent restraints are reassessed per policy, commonly every 2 hours.

Infant growth milestones

Birth weight doubles by 5–6 months and triples by 12 months. Head circumference increases about 1 cm per month for the first 6 months, then slows.

Folic acid in pregnancy

400 micrograms daily, started at least 1 month before conception and continued through the first trimester, reduces the risk of neural tube defects such as spina bifida.

Infant feeding first year

Breast milk or iron-fortified formula is the sole source of nutrition for about the first 6 months. Honey is withheld until 12 months because of infant botulism risk.

Toddler car seat guideline

The AAP recommends keeping children rear-facing until at least age 2, or until they reach the height or weight limit of the rear-facing car seat.

Gross motor milestones

Sits unsupported at 6–8 months, crawls at 8–10 months, pulls to stand around 10–12 months, and walks alone between 12 and 15 months.

Therapeutic communication techniques

Use open-ended questions, reflection, restating, clarifying, and silence. Avoid 'why' questions, false reassurance, giving personal advice, and changing the subject abruptly.

Kübler-Ross stages of grief

Denial, anger, bargaining, depression, and acceptance. The stages are not sequential, and clients may move back and forth among them rather than progressing in order.

Delirium tremens timing

Alcohol withdrawal delirium typically peaks 48–96 hours after the last drink. Signs include tachycardia, hypertension, diaphoresis, tremor, agitation, and hallucinations; benzodiazepines are the treatment.

Lithium toxicity signs

Therapeutic lithium is 0.6–1.2 mEq/L. Above that range expect coarse hand tremor, vomiting, diarrhea, ataxia, slurred speech, confusion, and possibly seizures.

Braden Scale purpose

Scores six subscales - sensory perception, moisture, activity, mobility, nutrition, and friction/shear - to predict pressure injury risk. A total of 18 or less indicates increased risk.

Repositioning to prevent pressure injury

Turn and reposition an immobile client at least every 2 hours, and more often when skin is already compromised, using a pressure-redistribution mattress or overlay.

Cold versus heat application

Cold reduces swelling and pain during the first 24–48 hours after acute injury. Heat relaxes muscle and increases blood flow but is avoided over fresh bleeding, edema, or impaired sensation.

Aspiration precautions for dysphagia

Position the client upright at 90 degrees, use a chin tuck, offer small bites, and follow the prescribed thickened-liquid and diet level. Keep suction equipment nearby.

Insulin mixing sequence

Inject air into the cloudy (NPH) vial, then air into the clear (regular) vial, and draw the clear insulin first. Regular insulin is the only type given intravenously.

Heparin antidote

Protamine sulfate reverses unfractionated heparin. Warfarin is reversed with vitamin K, and heparin-induced thrombocytopenia requires stopping heparin and starting a non-heparin anticoagulant.

Digoxin hold parameters

Withhold digoxin and notify the provider when the adult apical pulse is below 60 beats per minute. Hypokalemia increases the risk of digoxin toxicity.

IV drip rate formula

Drops per minute equals (volume in mL × drop factor in gtt/mL) divided by time in minutes. For example, 1,000 mL over 8 hours at 15 gtt/mL is about 31 gtt/min.

Transfusion reaction prevention

Verify the unit with a second nurse at the bedside, use only 0.9% sodium chloride as the compatible fluid, and remain with the client during the first 15 minutes of infusion.

Fall prevention interventions

Keep the bed lowest and locked, call light and belongings within reach, non-skid footwear on, and the path clear. Round hourly and assist with toileting.

Evisceration nursing action

Cover the protruding tissue with sterile dressings moistened with 0.9% sodium chloride, position in low Fowler's with knees flexed, keep the client NPO, and notify the surgeon immediately.

Neutropenic precautions

Place the client in a private room, exclude fresh flowers and plants, avoid raw fruits and vegetables, screen visitors for illness, and perform strict hand hygiene.

Airborne precautions diseases

Used for tuberculosis, measles, and varicella, requiring a negative-pressure room and an N95 respirator for staff. Standard precautions continue with all clients regardless of transmission route.

Hyperkalemia ECG changes

Tall, peaked T waves progress to a widened QRS and eventually a sine wave pattern. Treatment includes IV calcium gluconate, insulin with glucose, and a potassium binder.

Hypoglycemia 15-15 rule

For a conscious client with glucose below 70 mg/dL, give 15 g of fast-acting carbohydrate, recheck the glucose in 15 minutes, and repeat until it is above 70.

DKA diagnostic criteria

Glucose above 250 mg/dL, arterial pH below 7.3, bicarbonate below 18 mEq/L, and positive serum or urine ketones. Treatment begins with IV 0.9% sodium chloride, then insulin.

Cushing's triad

Hypertension with a widened pulse pressure, bradycardia, and irregular respirations. It is a late, life-threatening sign of increased intracranial pressure requiring urgent intervention.

Parkland burn formula

Give 4 mL of lactated Ringer's per kilogram of body weight per percent of total body surface area burned. Half is infused in the first 8 hours after injury, half over the next 16.