NLN ACE PN-RN flashcards

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

Cushing triad

Late sign of increased intracranial pressure: bradycardia, widened pulse pressure with hypertension, and irregular respirations. Report immediately because herniation risk is high.

Late decelerations

Fetal heart rate drops after a contraction begins and returns after it ends, indicating uteroplacental insufficiency. Reposition the mother, stop oxytocin, give oxygen, and notify the provider.

Magnesium sulfate toxicity antidote

Calcium gluconate. Magnesium sulfate is given for preeclampsia; monitor reflexes, respiratory rate, and urine output. Loss of deep tendon reflexes is an early toxicity sign.

APGAR components

Appearance, Pulse, Grimace, Activity, and Respiration, each scored 0-2 at 1 and 5 minutes after birth. A score of 7 or higher is generally reassuring.

Physiologic jaundice timing

Appears after the first 24 hours of life and peaks around days 3-5. Jaundice within the first 24 hours is always pathologic and needs immediate bilirubin measurement.

Kawasaki disease treatment

High-dose intravenous immunoglobulin and aspirin reduce coronary artery aneurysm risk. Fever lasting at least five days plus conjunctivitis, rash, and mucosal changes support diagnosis.

Epiglottitis nursing priority

Keep the child calm and never examine the throat with a tongue blade, because spasm can cause complete airway obstruction. Prepare for emergency intubation.

Pediatric weight-based dosing

Verify the ordered dose falls within the safe range per kilogram before giving. Children have higher metabolic rates and body water, so per-kg doses may exceed adult doses.

Digoxin toxicity signs

Nausea, anorexia, confusion, and visual halos or yellow-green vision. Hold the dose and check the apical pulse and potassium level before notifying the provider.

Warfarin antidote

Vitamin K. Warfarin inhibits vitamin K-dependent clotting factors; monitor INR with a typical target of 2-3 and teach bleeding precautions.

Heparin antidote

Protamine sulfate. Heparin therapy is monitored with aPTT and platelet counts; watch for heparin-induced thrombocytopenia and bleeding.

Naloxone purpose

Opioid antagonist given for respiratory depression and oversedation. Monitor respiratory rate and sedation level before and after opioid doses.

High-alert medications

Drugs with high harm risk when misused, including insulin, heparin, opioids, chemotherapy, and potassium chloride. Require independent double-check by a second nurse.

Aminoglycoside monitoring

Gentamicin and tobramycin are nephrotoxic and ototoxic. Monitor peak and trough levels, creatinine, and hearing; trough levels are drawn before the next dose.

Six rights of medication

Right client, drug, dose, route, time, and documentation. Verify two client identifiers and allergies before every administration.

Hand hygiene exceptions

Use soap and water rather than alcohol sanitizer for C. difficile and norovirus, because alcohol does not kill spores. Scrub at least 20 seconds.

Pressure injury stage 1

Intact skin with nonblanchable erythema. Reposition, relieve pressure, and document; do not massage the area.

Airborne precautions diseases

Tuberculosis, measles, and varicella require an N95 respirator and negative-pressure room. Droplet precautions cover influenza, pertussis, and meningitis.

Normal adult urine output

About 30 mL per hour or 0.5 mL/kg/hr. Output below this suggests hypovolemia or renal impairment and should be reported.

DKA fluid priority

Give isotonic IV fluids first, then insulin infusion. Add dextrose when glucose reaches about 200-250 mg/dL and monitor potassium closely.

COPD oxygen target

Keep SpO2 at 88-92% to avoid oxygen-induced hypercapnia. Administer bronchodilators before corticosteroids and encourage pursed-lip breathing.

Stroke thrombolytic window

Alteplase may be given within 3-4.5 hours of last known well time. Contraindications include BP above 185/110 and recent surgery.

Postpartum hemorrhage cause

Uterine atony is most common. Massage the fundus and empty the bladder; methylergonovine is contraindicated in hypertension and carboprost in asthma.

Cirrhosis encephalopathy signs

Asterixis, confusion, and altered sleep pattern signal hepatic encephalopathy. Monitor ammonia, limit protein as ordered, and give lactulose.

Intussusception presentation

Colicky pain with legs drawn up, currant-jelly stools, and a sausage-shaped mass. Air enema is diagnostic and therapeutic.

Croup treatment

Nebulized epinephrine for stridor at rest and dexamethasone. Barking cough and hoarse voice are typical; keep the child calm.

Febrile seizure response

Turn the child to the side and do not restrain or place anything in the mouth. Most occur between 6 months and 5 years and last under 15 minutes.

Insulin onset and peak

Rapid-acting lispro peaks in 1-3 hours; regular peaks in 2-4 hours; NPH peaks in 4-12 hours; glargine is peakless basal insulin.

Corticosteroid discontinuation

Do not stop abruptly because adrenal insufficiency can result. Taper the dose and monitor glucose, weight, and infection signs.

Lochia progression

Rubra is dark red for days 1-3, serosa pink-brown for days 4-10, and alba white-yellow after day 11. Saturating a pad in one hour warrants assessment.

Newborn cold stress

Cold stress increases oxygen consumption and causes metabolic acidosis. Dry the newborn immediately, use skin-to-skin contact, and maintain a normal axillary temperature.

Mandatory reporting red flags

Patterned injuries, injuries inconsistent with the stated history, and delay in seeking care require objective documentation and reporting under mandatory reporting laws.