NNC NLEN BSc flashcards

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

Nursing process steps

Assessment, diagnosis, planning, implementation, and evaluation form a continuous cycle in which evaluation findings feed back into reassessment and revised care planning.

Standard precautions

Infection control measures applied to all patients: hand hygiene, gloves for blood or body fluid contact, gowns and eye protection when splash exposure is likely.

Airborne precautions

Precautions for tuberculosis, measles, and varicella, requiring a negative-pressure room, N95 or higher respirator, and door kept closed except for entry and exit.

Pressure injury stage 1

Intact skin with a localized area of non-blanchable erythema, indicating tissue damage from pressure or shear before skin breakdown occurs.

Cardiac output formula

Cardiac output equals heart rate multiplied by stroke volume, normally about 4 to 8 liters per minute in a resting adult.

Normal arterial blood gas values

pH 7.35 to 7.45, PaCO2 35 to 45 mmHg, bicarbonate 22 to 26 mEq/L, and PaO2 80 to 100 mmHg on room air.

Starling forces

Capillary hydrostatic pressure drives fluid outward while plasma oncotic pressure, mainly from albumin, draws fluid inward; imbalance produces edema or dehydration.

RAAS sequence

Renin converts angiotensinogen to angiotensin I, ACE converts it to angiotensin II, causing vasoconstriction and aldosterone release that retains sodium and water.

First-pass metabolism

Orally absorbed drug travels through portal circulation to the liver before reaching systemic circulation, reducing bioavailability compared with intravenous or sublingual routes.

Digoxin therapeutic range

Serum digoxin levels of 0.5 to 2.0 ng/mL are therapeutic; toxicity causes nausea, visual halos, bradycardia, and arrhythmias and is aggravated by hypokalemia.

Warfarin antidote

Vitamin K (phytonadione) reverses warfarin effect; fresh frozen plasma or prothrombin complex concentrate is added for serious bleeding with elevated INR.

Narrow therapeutic index drugs

Drugs with small margin between therapeutic and toxic doses, such as lithium, phenytoin, digoxin, and warfarin, requiring serum level monitoring and careful titration.

Heart failure exacerbation signs

Dyspnea, orthopnea, bibasilar crackles, S3 gallop, jugular venous distention, and rapid weight gain from fluid retention signal decompensated heart failure.

Diabetic ketoacidosis criteria

Glucose above 250 mg/dL, arterial pH below 7.30, bicarbonate below 18 mEq/L, ketonemia, and anion gap above 10, treated with fluids, insulin, and potassium replacement.

Rule of nines

Burn surface estimate: each arm 9%, each leg 18%, anterior trunk 18%, posterior trunk 18%, head 9%, perineum 1%, used to calculate fluid resuscitation.

Naegele's rule

Estimated delivery date is calculated from the first day of the last menstrual period minus three months plus seven days, adding one year.

Late decelerations

Fetal heart rate drops after the contraction peak, reflecting uteroplacental insufficiency; respond by stopping oxytocin, repositioning left lateral, and giving oxygen and fluids.

Magnesium sulfate toxicity

Signs include loss of deep tendon reflexes, respiratory depression, and oliguria; calcium gluconate is the antidote and serum magnesium is monitored during infusion.

Apgar score components

Appearance, pulse, grimace, activity, and respiration, each scored 0 to 2 at one and five minutes after birth for a maximum of 10.

Pyloric stenosis signs

Projectile nonbilious vomiting at 3 to 6 weeks of age with an olive-shaped epigastric mass, causing hypochloremic hypokalemic metabolic alkalosis.

Intussusception presentation

Colicky abdominal pain with drawing up of the legs, currant-jelly stools, and a sausage-shaped mass; air or barium enema is diagnostic and often therapeutic.

Kawasaki disease criteria

Fever over five days plus conjunctivitis, oral mucosal changes, rash, extremity changes, and cervical lymphadenopathy; treated with IVIG and aspirin to prevent coronary aneurysm.

Serotonin syndrome signs

Agitation, hyperthermia, clonus, hyperreflexia, and diaphoresis caused by serotonergic excess, often from combining SSRIs with other serotonergic agents.

Lithium toxicity signs

Coarse tremor, vomiting, diarrhea, ataxia, and confusion with levels above 1.2 mEq/L; dehydration and NSAIDs raise risk by reducing renal lithium clearance.

Delirium tremens timing

Alcohol withdrawal delirium occurs 48 to 96 hours after the last drink, with tremor, hallucinations, autonomic instability, and seizures; benzodiazepines are first-line treatment.

Therapeutic communication techniques

Open-ended questions, reflection, restating, clarification, and silence encourage patient expression, unlike false reassurance, advice giving, or changing the subject.

Levels of prevention

Primary prevents disease before onset (immunization), secondary detects early disease (screening), and tertiary limits disability through rehabilitation and chronic disease management.

Incidence versus prevalence

Incidence counts new cases during a period; prevalence counts all existing cases at a point in time and rises when disease duration lengthens.

Sensitivity and specificity

Sensitivity is the proportion of truly diseased people testing positive; specificity is the proportion of truly healthy people testing negative.

Informed consent elements

Capacity, disclosure of risks and benefits, comprehension, and voluntariness; the provider obtains consent while the nurse witnesses and verifies understanding.

Delegation five rights

Right task, right circumstance, right person, right direction and communication, and right supervision; the delegating nurse retains accountability for outcomes.

Evidence hierarchy

Systematic reviews and meta-analyses of randomized trials rank highest, followed by randomized trials, cohort studies, case-control studies, case series, and expert opinion.