NLN ACE PN-RN key terms

A drop in blood pressure of at least 20 mmHg systolic or 10 mmHg diastolic when a client moves from lying to sitting or standing. It causes dizziness and falls, so teach clients to rise slowly and dangle the legs first.

Measures that reduce a client's risk of falling, such as bed in low position, call light within reach, nonskid footwear, side rails as ordered, and hourly rounding. Apply them to clients who are sedated, weak, or have gait or vision problems.

Devices or medications that limit a client's freedom of movement. Use only when less restrictive measures fail, with a provider's order and time limits, frequent monitoring, and documentation. Never use them for convenience or discipline.

Recording of all fluids a client takes in and puts out, measured in milliliters. Accurate totals help detect dehydration, fluid overload, and kidney problems. Report a significant imbalance or output below 30 mL per hour.

Weighing a client at the same time each day, on the same scale, wearing similar clothing. It is the most reliable indicator of fluid gain or loss; a gain of 1 kg equals about 1 liter of retained fluid.

Practices that prevent microorganisms from entering the body. Medical asepsis reduces the spread of germs through hand hygiene and clean technique; surgical asepsis keeps objects sterile during procedures such as catheter insertion or dressing changes.

Infection control steps applied to every client, whatever the diagnosis. They include hand hygiene, gloves for body fluids, and eye or face protection when splash is likely. They protect both the nurse and the client.

An area free of all microorganisms, created by opening sterile packaging and keeping it in view. Only sterile items touch it, and anything wet or outside the visible area is contaminated. Used for wound care and invasive procedures.

A client's voluntary agreement to a procedure after receiving the diagnosis, purpose, risks, benefits, and alternatives. The provider explains and obtains consent; the nurse witnesses the signature and confirms the client understands.

A written document stating a client's wishes for care if the client cannot speak for themselves. Examples include a living will and a durable power of attorney for health care. The nurse confirms it is on the chart and honors it.

Localized damage to skin and underlying tissue from prolonged pressure, often over bony areas such as the sacrum or heels. Prevention includes turning, repositioning, keeping skin clean and dry, and using pressure-relieving surfaces.

A scored tool that estimates a client's risk of developing a pressure injury. It rates sensory perception, moisture, activity, mobility, nutrition, and friction or shear. Lower scores mean higher risk and prompt more frequent skin checks.

The body's repair of damaged tissue through stages: hemostasis, inflammation, proliferation, and maturation. Healing needs adequate nutrition, oxygen, and blood flow. Signs of infection such as redness, warmth, or pus should be reported.

Swelling caused by excess fluid trapped in body tissues. It may be pitting, leaving an indentation after pressure. Elevate the limb, monitor weight, and report sudden or worsening edema, which can signal heart or kidney failure.

Shortness of breath or difficult, uncomfortable breathing. The nurse assesses rate, effort, oxygen saturation, and position the client assumes. Sitting upright, oxygen as ordered, and staying with the client help; report worsening distress promptly.

A noninvasive sensor, usually on a finger, that estimates the percentage of hemoglobin carrying oxygen. Values below the ordered range should be verified and reported. Poor circulation, nail polish, and motion can distort readings.

A device a client inhales through slowly and deeply to expand the lungs, usually ten times an hour while awake. It helps prevent atelectasis after surgery or during bed rest. Splint the incision and coach correct technique.

Collapse of part of a lung, so air sacs do not fill. It causes low oxygen, rapid shallow breathing, and crackles. Encourage deep breathing, coughing, early ambulation, and incentive spirometry to prevent it after surgery.

Insertion of a tube through the urethra into the bladder to drain urine. Use sterile technique, secure the tubing, keep the bag below bladder level, and remove the catheter as soon as possible to reduce infection risk.

Sounds made by movement of the intestines, assessed by listening in all four quadrants before palpating. Normal sounds are soft clicks and gurgles. Absent sounds after surgery can signal ileus and must be reported.

Temporary paralysis of the intestines that stops normal movement, often after abdominal surgery or with electrolyte imbalance. Signs include absent bowel sounds, distention, nausea, and no flatus. Treatment includes nothing by mouth and decompression.

The time from injecting insulin until it begins lowering blood glucose. Rapid-acting insulin starts in about 15 minutes, short-acting in 30 to 60 minutes, and intermediate-acting in 1 to 2 hours. Timing guides meal and snack scheduling.

The time when an insulin dose has its strongest glucose-lowering effect. Knowing the peak helps the nurse watch for hypoglycemia. For example, regular insulin peaks in 2 to 4 hours, so monitor the client around that time.

Blood glucose below about 70 mg/dL, causing shakiness, sweating, confusion, or hunger. If the client can swallow, give 15 g of fast carbohydrate and recheck in 15 minutes. If unresponsive, give glucagon or IV dextrose as ordered.

The blood concentration range in which a drug is most effective with the least toxicity. For drugs such as digoxin or lithium, the nurse draws blood at the ordered time and reports values outside the range before giving the next dose.

Harmful effects of too much digoxin, including nausea, visual changes such as yellow-green halos, confusion, and irregular pulse. Hold the dose, check the apical pulse, and notify the provider; a low potassium level raises risk.

The heartbeat heard with a stethoscope at the fifth intercostal space, left midclavicular line. Count for a full minute before giving drugs such as digoxin. Hold the dose and report a rate below the ordered limit.

A formal comparison of all medications a client is taking with new orders at admission, transfer, and discharge. It catches duplication, omissions, and interactions and is a key defense against medication errors.

The checks performed before giving any drug: right client, right drug, right dose, right route, right time, and right documentation. Verify using two identifiers and scan or check the label against the order.

A muscle chosen for deep injection, such as the ventrogluteal, vastus lateralis, or deltoid. Select based on client age, muscle mass, and volume. The ventrogluteal site is preferred for adults because it avoids major nerves and vessels.

Injection into fatty tissue beneath the skin, used for insulin and heparin. Pinch the tissue, insert at a 45- to 90-degree angle depending on tissue depth, and rotate sites. Do not aspirate or massage the site.

Gravida is the number of times a woman has been pregnant, including the current pregnancy. Para is the number of births after 20 weeks of gestation. Together they summarize obstetric history, written as GTPAL in expanded form.

An obstetric history format: gravida, term births, preterm births, abortions, and living children. For example, a woman pregnant for the third time with one term birth and one miscarriage is G3 T1 P0 A1 L1.

The projected delivery date, often calculated by Naegele's rule: first day of the last menstrual period minus 3 months plus 7 days. Ultrasound can confirm or adjust the date, especially when cycles are irregular.

The baby's heartbeat, normally 110 to 160 beats per minute. It is monitored for baseline rate, variability, accelerations, and decelerations. Persistent decelerations or very low variability require repositioning and prompt reporting.

A drop in fetal heart rate that begins after the peak of a uterine contraction and returns after it ends. It suggests poor placental blood flow. Turn the mother onto her side, give oxygen, stop oxytocin, and notify the provider.

Tightening and relaxing of the uterus during labor, assessed for frequency, duration, and intensity. Strong, frequent contractions with little rest between them can reduce fetal oxygen and should be reported.

Heavy bleeding after birth, often defined as more than 500 mL after a vaginal birth or 1000 mL after a cesarean. The most common cause is a soft, boggy uterus. Massage the fundus, give oxytocin as ordered, and report.

Checking the uterus after birth for height, position, and firmness by placing a hand on the abdomen. A firm fundus at the umbilicus is expected early on. A boggy uterus with heavy bleeding calls for massage and provider notification.

A newborn's ability to keep a stable body temperature, which is limited by large surface area and little fat. Cold stress raises oxygen needs and glucose use. Dry the baby, use skin-to-skin contact, and keep the room warm.

Yellowing of a newborn's skin and eyes from a buildup of bilirubin. It is common in the first week and is monitored with skin checks and blood levels. Feeding well and phototherapy as ordered help lower bilirubin.

A quick newborn assessment at 1 and 5 minutes after birth. It scores heart rate, breathing effort, muscle tone, reflex response, and color from 0 to 2 each. Scores of 7 or above are generally reassuring.

Calculating a child's drug dose from body weight in kilograms, often as milligrams per kilogram per dose. Weigh the child, convert pounds to kilograms, and check that the ordered dose is safe for the child's size before giving it.

The recommended minimum and maximum dose of a drug for a client's weight or age. The nurse compares the ordered dose with the reference range and questions orders that fall outside it before administration.

The amount of fluid a child needs each day, commonly estimated by the 4-2-1 rule: 4 mL/kg for the first 10 kg, 2 mL/kg for the next 10 kg, and 1 mL/kg for each remaining kilogram. Children dehydrate quickly because of their higher body water.

Loss of body fluid that a child cannot replace, causing dry mouth, few or no tears, sunken eyes, and less urine. Infants and toddlers decline fast. Assess weight, urine output, and mucous membranes, and encourage oral fluids.

Checking the soft spots on a baby's skull: the anterior fontanel closes by about 18 months, the posterior by 2 to 3 months. A sunken fontanel suggests dehydration; a bulging one suggests increased pressure and needs prompt reporting.

A theory of psychosocial development across the lifespan, each stage pairing a task with a conflict. Examples include trust versus mistrust in infancy and industry versus inferiority in school age. It guides age-appropriate care and teaching.

A theory of cognitive development: sensorimotor, preoperational, concrete operational, and formal operational. It explains how children understand illness and instructions, helping the nurse choose words and teaching methods for each age.