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Rapid review flashcards for [[Fundamentals of Nursing]] at registered nurse depth, emphasizing assessment, clinical judgment, prioritization, delegation, and evaluation of outcomes.

== Nursing process and clinical judgment ==

;What are the five steps of the nursing process, in order?
:Assessment, diagnosis or analysis, planning, implementation, and evaluation (ADPIE). The process is cyclical, so evaluation feeds back into reassessment.

;How does a nursing diagnosis differ from a medical diagnosis?
:A medical diagnosis names a disease and is treated by the provider. A nursing diagnosis names a human response to an actual or potential health problem that nurses are licensed to treat independently, and it changes as the patient's response changes.

;What are the three parts of an actual nursing diagnosis?
:Problem, etiology (related to), and defining characteristics (as evidenced by). A risk diagnosis has only the problem and the risk factors, because the problem has not yet occurred and there are no signs and symptoms.

;What are the characteristics of a correctly written expected outcome?
:Patient centered, specific, measurable, attainable, realistic, and time limited. It states the patient's behavior with the conditions and a deadline, not the nurse's action.

;What priority frameworks does the registered nurse use, and in what order?
:Airway, breathing, and circulation first. Then Maslow's hierarchy, with physiologic needs before safety and psychosocial needs. Then acute before chronic, unstable before stable, and unexpected before expected.

;When should the nurse assess before intervening, and when not?
:Assess first in almost every situation. Act first only when an emergency demands an immediate, obvious action, such as an obstructed airway, an unwitnessed collapse, or a patient found lying flat during tube feeding.

;What does the nurse do when an expected outcome is only partially met?
:Return to assessment, identify the barrier, and revise the diagnosis, outcome, or interventions. Do not document the outcome as met, and do not abandon a realistic goal.

== Delegation and supervision ==

;What are the five rights of delegation?
:Right task, right circumstance, right person, right direction and communication, and right supervision and evaluation.

;Which steps of the nursing process may not be delegated?
:Assessment, nursing diagnosis, planning and care plan development, initial teaching, and evaluation. Only implementation of selected tasks may be delegated, and the registered nurse retains accountability for the outcome.

;Which tasks are appropriate to delegate to assistive personnel?
:Standard, unchanging tasks with predictable outcomes for stable patients: bathing, feeding a patient without dysphagia, oral care, ambulating, transferring, positioning, toileting, measuring vital signs, recording intake and output, and applying compression devices. The nurse verifies and interprets all reported data.

== Mobility and skin integrity ==

;What are the major systemic hazards of immobility?
:Muscle atrophy, contractures, and foot drop; orthostatic hypotension and venous thromboembolism; atelectasis and hypostatic pneumonia; pressure injury; constipation and impaction; urinary stasis, calculi, and infection; and depression and disorientation.

;How often should patients be repositioned, and what head of bed angle limits shear?
:At least every two hours in bed and at least every hour in a chair, with chair bound patients taught to shift weight every 15 minutes. Keep the head of the bed at or below 30 degrees when possible, because higher angles increase sacral shear. Meals and enteral feeding are exceptions and require at least 30 degrees.

;What does the Braden Scale measure, and what score indicates risk?
:Six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction and shear. Lower total scores mean higher risk, and a score of 18 or less generally indicates risk in adults.

;How are pressure injuries staged?
:Stage 1 is intact skin with nonblanchable erythema. Stage 2 is partial thickness dermal loss, a shallow open ulcer or a serum filled blister. Stage 3 is full thickness with visible fat but no exposed bone, tendon, or muscle. Stage 4 is full thickness with exposed bone, tendon, or muscle. Unstageable means the base is obscured by slough or eschar. A deep tissue pressure injury is persistent nonblanchable deep red, maroon, or purple discoloration or a blood filled blister.

;Which two commonly suggested measures are actually contraindicated in pressure injury prevention?
:Massaging reddened bony prominences, which worsens already damaged tissue, and donut or ring cushions, which concentrate pressure at the rim and impair circulation.

== Vital signs ==

;What are the adult reference ranges for the standard vital signs?
:Temperature about 36.5 to 37.5 degrees Celsius (97.7 to 99.5 degrees Fahrenheit) orally, pulse 60 to 100 beats per minute, respirations 12 to 20 breaths per minute, blood pressure below 120 over 80 millimeters of mercury for normal, and oxygen saturation about 95 to 100 percent on room air.

;What defines a positive orthostatic vital sign finding?
:A drop of at least 20 millimeters of mercury systolic or at least 10 millimeters of mercury diastolic within three minutes of standing, or symptoms such as dizziness or visual change. Measure supine, then sitting, then standing, allowing one to three minutes between positions.

;How does cuff size and technique affect blood pressure accuracy?
:The bladder width should be about 40 percent of arm circumference and the length about 80 percent. A cuff that is too narrow, applied over clothing, or used with the arm below heart level gives a falsely high reading. A cuff that is too wide gives a falsely low reading.

;When must the nurse hold digoxin, and how is the pulse assessed?
:Assess the apical pulse at the fifth intercostal space, left midclavicular line, for one full minute. Hold the dose and notify the provider if the adult apical rate is below 60 beats per minute, because further bradycardia may signal toxicity.

;When is pulse oximetry unreliable?
:With poor perfusion, hypothermia, vasoconstriction, hypotension, motion, dark nail polish, and carbon monoxide poisoning, in which the reading may be falsely normal because the oximeter cannot distinguish carboxyhemoglobin from oxyhemoglobin.

== Pain, sleep, and elimination ==

;What is the most reliable indicator of pain?
:The patient's self report. Normal vital signs never disprove pain, because autonomic responses habituate in persistent pain.

;Which pain assessment tool matches which patient?
:The 0 to 10 numeric rating scale for most adults, Wong Baker FACES for children roughly three years and older, FLACC for infants and nonverbal children, and PAINAD or the Critical Care Pain Observation Tool for adults who cannot self report, such as those with advanced dementia or on mechanical ventilation.

;What is the earliest warning sign of opioid induced respiratory depression, and which side effect never resolves with tolerance?
:Increasing sedation is the earliest warning sign and precedes respiratory depression. Constipation is the effect to which tolerance does not develop, so a bowel regimen begins when the opioid begins.

;What is the central safety principle of patient controlled analgesia?
:Only the patient presses the button. The patient's own sedation is the built in dose limit, so proxy dosing by family or staff removes the safeguard and can cause oversedation.

;Which sleep stage is most restorative, and how does aging change sleep?
:Non rapid eye movement stage N3 slow wave sleep is the most physically restorative and predominates early in the night. Older adults need a similar total sleep time but obtain less N3, wake more frequently, and shift toward earlier sleep and wake times.

;What is the minimum acceptable adult urine output?
:About 30 milliliters per hour, or 0.5 milliliters per kilogram per hour. Sustained output below this threshold must be reported.

;What are the key nursing measures to prevent catheter associated urinary tract infection?
:Insert only when indicated and remove as early as possible, use sterile insertion technique, maintain a closed system, secure the tubing, keep the bag below the bladder and off the floor, avoid dependent loops, sample from the port, and avoid routine irrigation.

;What is the classic presentation of fecal impaction?
:Frequent small amounts of liquid stool leaking around a hardened mass, often mistaken for diarrhea, typically in an immobile patient or a patient receiving opioids. Treating it with antidiarrheals worsens the impaction.

== Safety and communication ==

;When must soap and water be used instead of alcohol based hand rub?
:When hands are visibly soiled, after using the restroom, and when caring for a patient with ''Clostridioides difficile'' or another spore forming organism, because alcohol does not kill spores.

;What does SBAR stand for, and when is it used?
:Situation, background, assessment, and recommendation. It structures handoff communication, transfers of care, and provider notification, and it reduces omission errors.

[[Category:Fundamentals of Nursing]]
[[Category:Registered Nurse (NCLEX-RN)]]
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Fundamentals of Nursing – RN Flashcards - Revision history

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