NLN NEX flashcards
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32 cards. Read the term and the definition here. The deck at the top of this page is optional.
- Six rights of medication
- Right client, right drug, right dose, right route, right time, and right documentation. The nurse verifies each right before administering any medication to prevent errors and client harm.
- RACE fire response sequence
- Rescue anyone in immediate danger, sound the Alarm, Contain the fire by closing doors, then Extinguish or Evacuate. The order prioritizes saving lives before protecting property.
- Restraint reassessment interval
- Circulation, skin integrity, and continued need are assessed at least every 15 to 30 minutes, with release and range-of-motion exercise at least every 2 hours under federal rules.
- Informed consent requirements
- The client must be competent, receive full disclosure of risks, benefits, and alternatives, comprehend the information, and consent voluntarily. The provider obtains consent and the nurse verifies it.
- Delegation to assistive personnel
- Only tasks that are predictable, routine, and within the aide's training may be delegated; assessment, teaching, and evaluation stay with the registered nurse.
- Sentinel event reporting
- An unexpected death or serious permanent harm is a sentinel event. Accreditors require a root-cause analysis, and reporting to The Joint Commission occurs within 5 business days.
- Emergency Severity Index levels
- A five-level triage scale in which level 1 requires immediate life-saving intervention, level 2 is high risk, and levels 3 through 5 are ranked by resources needed.
- Standard precautions apply to
- Every client regardless of diagnosis. Gloves are worn for contact with blood or body fluids, and hand hygiene is the single most effective way to prevent infection.
- Infant head control milestone
- Most infants lift the head and chest when prone and gain head control by about 3 to 4 months; absent head control at 6 months warrants developmental evaluation.
- Folic acid preconception dose
- 400 micrograms daily, begun at least one month before conception, reduces the risk of neural tube defects such as spina bifida in the developing fetus.
- Fundal height estimation
- Between about 20 and 36 weeks of gestation, fundal height in centimeters roughly equals gestational age in weeks; a discrepancy over 3 cm suggests further evaluation.
- Exclusive breastfeeding duration
- Infants receive only breast milk, without water or formula, for about the first 6 months; iron-rich complementary foods are then introduced while breastfeeding continues.
- Prenatal weight gain normal BMI
- A woman with a normal prepregnancy body mass index should gain roughly 11 to 16 kilograms, or 25 to 35 pounds, across pregnancy, mostly in the second and third trimesters.
- Erikson infancy stage
- Trust versus mistrust: an infant whose needs are consistently met develops trust, while inconsistent or neglectful care fosters mistrust that affects later relationships.
- Pneumococcal vaccine recommendation
- Adults aged 65 and older, plus younger adults with specified risk conditions, should receive pneumococcal vaccination to prevent invasive pneumococcal disease.
- Hypertension diagnostic threshold
- Under current United States guidelines, a systolic pressure of 130 mm Hg or higher or a diastolic of 80 mm Hg or higher on repeated readings defines hypertension.
- Kubler-Ross grief stages
- Denial, anger, bargaining, depression, and acceptance. The stages are neither sequential nor universal; clients may move back and forth or skip stages entirely.
- Therapeutic communication techniques
- Open-ended questions, silence, reflection, restating, and general leads encourage clients to express feelings; avoid false reassurance and 'why' questions that imply judgment.
- Suicide risk assessment rule
- Ask directly about suicidal thoughts, plan, intent, and access to means. Inquiring about suicide does not increase risk and is needed to determine observation level.
- Alcohol withdrawal signs
- Tremor, sweating, tachycardia, anxiety, and insomnia begin within hours of the last drink; hallucinations, seizures, and delirium tremens may follow and can be fatal.
- Refeeding syndrome risk
- Restarting nutrition in a severely malnourished client shifts phosphate, potassium, and magnesium into cells; monitor electrolytes and advance feeding slowly under medical supervision.
- Defense mechanism denial
- Refusing to accept a reality that causes anxiety, such as insisting a terminal diagnosis is a mistake. It operates unconsciously and protects the ego from distress.
- Electroconvulsive therapy preparation
- The client needs informed consent, nothing by mouth after midnight, and an ordered anticholinergic to reduce secretions; temporary confusion and short-term memory loss are expected.
- Crisis intervention focus
- Treatment is brief and targets the immediate problem, helping the client regain equilibrium and cope with the current stressor rather than resolving long-standing issues.
- Normal arterial blood gas values
- pH 7.35 to 7.45, PaCO2 35 to 45 mm Hg, and bicarbonate 22 to 26 mEq/L. Values outside these ranges indicate an acid-base imbalance needing interpretation.
- Hyperkalemia emergency treatment
- Give intravenous calcium gluconate first to protect the myocardium, then insulin with glucose and possibly albuterol to shift potassium into cells while excess is removed.
- Digoxin therapeutic range
- Approximately 0.5 to 2.0 ng/mL. Anorexia, nausea, and yellow-green visual halos suggest early toxicity, which hypokalemia and renal impairment both increase.
- Warfarin monitoring and antidote
- Monitor prothrombin time and INR, targeting 2 to 3 for most indications. Vitamin K is the antidote, and fresh frozen plasma reverses severe bleeding.
- Transfusion reaction first action
- Stop the transfusion immediately, keep the intravenous line patent with normal saline using new tubing, then notify the provider and monitor vital signs closely.
- Chest tube water seal bubbling
- Tidaling with respiration is normal in the water seal chamber; continuous bubbling there indicates an air leak that must be assessed and reported.
- Increased intracranial pressure positioning
- Elevate the head of the bed 30 degrees, keep the head midline, avoid hip flexion and Valsalva, and maintain PaCO2 near 35 to 45 mm Hg to limit pressure rise.
- Hypoglycemia signs and threshold
- Blood glucose below 70 mg/dL with shakiness, sweating, palpitations, and confusion. A conscious client receives 15 grams of fast-acting carbohydrate and is rechecked in 15 minutes.