NCLEX-RN 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 and communication, right supervision and evaluation. The RN retains accountability for assessment, teaching, evaluation, and the care plan even after delegating.

SBAR Handoff

Situation, Background, Assessment, Recommendation: a structured format for handoffs and urgent reports to providers that reduces omissions and improves patient safety.

Mass Casualty Triage Colors

Red is immediate and life-threatening, yellow is delayed or serious, green is minor or walking wounded, and black is deceased or expectant. Clients are sorted by survivability, not arrival order.

Incident Report Rules

Complete a variance report after an unusual event for risk management, but never file it in the client's chart or mention it in nursing notes. Chart only objective facts.

Alcohol Rub Limits

Alcohol-based rub does not kill C. difficile or norovirus spores, so use soap and water for these organisms. Hand hygiene remains the single most effective way to prevent infection.

Airborne Precautions

Negative-pressure room with the door closed and an N95 respirator for pulmonary tuberculosis, measles, varicella, and disseminated shingles. Only staff with documented immunity should care for measles or varicella clients.

Droplet Precautions

Private room and a surgical mask when working within about 3 to 6 feet, used for influenza, pertussis, mumps, rubella, meningococcal meningitis, and diphtheria. The client wears a mask during transport.

Restraint Order Time Limits

Adults need a provider order renewed every 4 hours, ages 9 to 17 every 2 hours, and children under 9 every 1 hour. Face-to-face evaluation occurs within 1 hour; circulation and range of motion are checked every 2 hours.

Erikson Infancy Stage

Trust versus mistrust, birth to about 1 year: consistent, responsive caregiving builds trust, while inconsistent or neglectful care fosters mistrust and affects later relationships.

Fontanel Closure Timing

The anterior fontanel closes between 12 and 18 months; the posterior closes by 6 to 8 weeks. A sunken fontanel suggests dehydration, and a bulging one suggests increased intracranial pressure.

Infant Growth Milestones

Birth weight doubles by 5 to 6 months and triples by 12 months. Birth length increases about 50 percent by 12 months, and head circumference grows fastest during the first 6 months.

Tdap in Pregnancy

Tdap is given during every pregnancy, ideally at 27 to 36 weeks, so antibody transfers to the newborn. Live vaccines such as MMR, varicella, and nasal influenza are contraindicated in pregnancy.

Therapeutic Communication Techniques

Open-ended questions, reflection, restating, clarifying, silence, and stating observations encourage expression. Avoid why questions, false reassurance, giving advice, and changing the subject.

Delirium Tremens Timing

Withdrawal seizures appear 6 to 48 hours after the last drink; delirium tremens peaks at 48 to 96 hours with tachycardia, hypertension, fever, tremor, and hallucinations. Benzodiazepines are first-line treatment.

Refeeding Syndrome Risk

Reintroducing nutrition in severe anorexia or prolonged starvation can trigger dangerous shifts in phosphate, potassium, and magnesium. Monitor electrolytes and start feedings low and advance slowly.

Suicide Risk Assessment

Asking directly about suicide does not increase risk. The highest risk is a specific plan with access to lethal means, so provide direct observation, remove hazards, and arrange urgent psychiatric evaluation.

FLACC Pain Scale

Face, Legs, Activity, Cry, Consolability: each scored 0 to 2 for a 0 to 10 total. It is used for infants and for nonverbal or cognitively impaired clients who cannot self-report pain.

Adult Enema Positioning

Place the adult in the left side-lying (Sims) position so the solution flows along the descending colon, and keep the container about 12 to 18 inches above the client.

Cane Placement Side

Hold the cane on the stronger, unaffected side and advance it together with the weaker leg. The handle should reach the greater trochanter when the arm hangs at the side.

Oral Care When Unconscious

Turn the client to a side-lying position with suction available, use a soft toothbrush with minimal water, and never insert fingers or lemon-glycerin swabs into the mouth.

IV Drip Rate Formula

Gtt/min equals volume in mL multiplied by drop factor in gtt/mL, divided by time in minutes. For mL/hr, divide the total volume by the number of hours.

Heparin Antidote

Protamine sulfate reverses heparin. Vitamin K reverses warfarin, naloxone reverses opioids, flumazenil reverses benzodiazepines, and acetylcysteine reverses acetaminophen overdose.

Insulin Onset Times

Lispro and aspart start in about 15 minutes; regular insulin in 30 to 60 minutes; NPH peaks in 4 to 12 hours; glargine is a peakless basal insulin. Only regular insulin may be given intravenously.

Transfusion Reaction Actions

Stop the transfusion immediately, keep the line patent with 0.9 percent sodium chloride, assess vital signs, notify the provider and blood bank, and return the bag and tubing.

Normal Serum Potassium

Normal serum potassium is 3.5 to 5.0 mEq/L. Levels above 5.0 cause peaked T waves and dysrhythmias; levels below 3.5 cause flat T waves, U waves, and muscle weakness.

ABG Normal Values

pH 7.35 to 7.45, PaCO2 35 to 45 mm Hg, bicarbonate 22 to 26 mEq/L, PaO2 80 to 100 mm Hg. ROME means respiratory opposite and metabolic equal when interpreting the primary disorder.

Heparin-Induced Thrombocytopenia

A platelet count falling by 50 percent or more, or below 100,000, five to ten days after starting heparin suggests heparin-induced thrombocytopenia. Stop all heparin and expect a non-heparin anticoagulant.

Preventing Postoperative Atelectasis

Incentive spirometry every 1 to 2 hours while awake, splinting the incision, early ambulation, and adequate analgesia reduce atelectasis and pneumonia after surgery.

Cushing's Triad

Hypertension with a widened pulse pressure, bradycardia, and irregular respirations indicate rising intracranial pressure and impending herniation. Report these findings immediately.

DKA Versus HHS

DKA shows hyperglycemia with ketones, anion-gap metabolic acidosis, and Kussmaul respirations. HHS shows glucose often above 600 mg/dL, high osmolality, profound dehydration, and minimal ketones.

Anaphylaxis First-Line Drug

Epinephrine 0.3 to 0.5 mg of a 1:1000 solution given intramuscularly in the vastolateral thigh is first-line treatment and is repeated every 5 to 15 minutes as needed.

Parkland Burn Formula

Give 4 mL times body weight in kg times percent total body surface area burned over 24 hours with lactated Ringer's; half is given in the first 8 hours from the time of injury.