PN Level 1 flashcards

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

SBAR handoff

Structured communication tool: Situation, Background, Assessment, Recommendation. It standardizes transfer of client information between caregivers and reduces omissions during shift change or provider notification.

Five rights of delegation

Right task, right circumstance, right person, right direction and communication, right supervision and evaluation. The RN retains accountability for the outcome of any delegated task.

Informed consent elements

Client has capacity, receives disclosure of risks, benefits, and alternatives, acts voluntarily, and signs. The provider obtains consent; the nurse witnesses and verifies understanding.

Chain of command

Hierarchical route for resolving concerns: charge nurse, then provider, then nurse manager or supervisor, then administration. Each step is documented contemporaneously.

Airborne precautions

Used for tuberculosis, measles, and varicella. Requires a negative-pressure room, N95 respirator, and door kept closed. Standard precautions continue in addition.

Droplet precautions

Used for influenza, pertussis, and meningococcal meningitis. Requires a surgical mask within about 3 feet of the client; door may remain open.

Contact precautions

Used for MRSA, C. difficile, and scabies. Requires gown and gloves on room entry, dedicated equipment, and hand hygiene with soap and water for C. difficile.

RACE fire response

Rescue anyone in danger, Alarm the fire alarm, Contain the fire by closing doors, Extinguish or Evacuate. Used as the standard nursing response to fire.

Restraint order limits

Restraints require a provider order, least restrictive device, time-limited duration, face-to-face evaluation, and frequent monitoring of circulation, skin, hydration, and range of motion.

Erikson toddler stage

Autonomy versus shame and doubt, roughly ages 1 to 3. Toddlers assert independence through choices and control; caregivers should offer safe options and tolerate negativism.

Prenatal folic acid

400 micrograms daily starting before conception reduces neural tube defects such as spina bifida. Higher doses are used with prior affected pregnancy or certain medications.

Normal newborn vitals

Weight 2.5 to 4 kg, heart rate 110 to 160 beats per minute, respirations 30 to 60 per minute, axillary temperature 36.5 to 37.5 degrees Celsius.

Colorectal screening age

Average-risk adults begin colorectal cancer screening at age 45, using colonoscopy, stool-based testing, or other approved methods. Earlier screening applies with family history or symptoms.

Therapeutic communication techniques

Open-ended questions, reflection, restating, clarification, silence, and offering self. Avoid why questions, false reassurance, approval, and giving personal advice.

Kubler-Ross grief stages

Denial, anger, bargaining, depression, and acceptance. Stages are not linear, may overlap, and are not required for a healthy grief response.

Alcohol withdrawal timeline

Symptoms begin 6 to 24 hours after the last drink; seizures and delirium tremens peak at 48 to 96 hours. Benzodiazepines and thiamine are standard treatment.

Suicide risk assessment

Ask directly about ideation, plan, means, intent, and prior attempts. Direct questioning does not increase risk. A no-suicide contract does not replace observation and safety measures.

Braden scale

Validated tool scoring sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Lower scores indicate higher pressure injury risk and guide prevention.

Pressure injury staging

Stage 1 is nonblanchable erythema; stage 2 partial-thickness loss; stage 3 full-thickness with visible fat; stage 4 exposes bone or tendon; unstageable has eschar.

Wong-Baker FACES scale

Pain tool using six faces from no hurt to worst hurt, used for children and clients who can self-report. Not valid for clients unable to understand the scale.

IV drip rate formula

Drops per minute equals (volume in milliliters times drop factor in drops per milliliter) divided by minutes of infusion. Drop factor is printed on the tubing package.

Digoxin administration rule

Count the apical pulse for one full minute before giving; hold and notify the provider if the adult rate is below 60. Monitor potassium because hypokalemia increases toxicity risk.

Heparin antidote

Protamine sulfate reverses heparin. Monitor aPTT for unfractionated heparin; monitor anti-Xa for low-molecular-weight heparin. Warfarin is reversed with vitamin K.

High-alert medications

Drugs with high risk of harm when misused: insulin, heparin, opioids, chemotherapy, and concentrated electrolytes. Require independent double-checks and standardized dosing.

Normal adult potassium

3.5 to 5.0 mEq/L. Hyperkalemia causes peaked T waves and dysrhythmias; hypokalemia causes U waves, muscle weakness, and ileus.

Preoperative NPO guidelines

Typically no solid food for 8 hours and no clear liquids for 2 hours before surgery. Verify the order and remove valuables, dentures, and jewelry.

DVT prevention measures

Sequential compression devices, early ambulation, hydration, and anticoagulation as ordered. Assess for unilateral calf pain, warmth, and swelling; do not massage the leg.

Hypoglycemia treatment

Glucose below 70 mg/dL. If conscious, give 15 grams fast-acting carbohydrate and recheck in 15 minutes. If unconscious, give glucagon or IV dextrose.

Sepsis bundle essentials

Measure lactate, draw blood cultures before antibiotics, give broad-spectrum antibiotics promptly, and give 30 mL/kg crystalloid for hypotension or lactate of 4 or higher.

COPD oxygen target

Titrate oxygen to a saturation of 88 to 92 percent in clients at risk for carbon dioxide retention. Use low-flow oxygen and monitor respiratory status closely.

Rule of nines

Estimates burn surface area: each arm 9 percent, each leg 18 percent, anterior trunk 18 percent, posterior trunk 18 percent, head 9 percent, perineum 1 percent.

Mandatory reporting duty

Nurses must report suspected child, elder, or dependent adult abuse, certain communicable diseases, and impaired colleagues per state law. Reporting is not optional.

Incident report rule

Complete an incident report for unusual events; do not place it in the medical record or copy it for the client. Document objective client findings in the chart.