Reduction of Risk Potential – LPN Flashcards

Rapid-review flashcards for Reduction of Risk Potential at NCLEX-PN depth, emphasizing normal parameters, recognition of abnormal findings, standard pre-procedure and post-procedure care, and prompt reporting to the registered nurse. Reference ranges are conventional teaching values; always confirm against the reporting laboratory's own range and follow facility policy and the state nurse practice act.

Normal Parameters to Know Cold

Adult vital sign ranges at rest

Temperature about 36.5 to 37.5 degrees Celsius (97.7 to 99.5 degrees Fahrenheit) orally, heart rate 60 to 100 beats per minute, respirations 12 to 20 breaths per minute, blood pressure below 120/80 mm Hg as the normal category, and oxygen saturation 95 to 100 percent.

Normal serum sodium and potassium

Sodium 135 to 145 mEq/L. Potassium 3.5 to 5.0 mEq/L.

Normal serum calcium and magnesium

Total calcium about 9.0 to 10.5 mg/dL. Magnesium about 1.3 to 2.1 mEq/L.

Normal blood urea nitrogen and serum creatinine

Blood urea nitrogen 10 to 20 mg/dL. Creatinine about 0.6 to 1.2 mg/dL.

Normal hemoglobin and hematocrit for adults

Hemoglobin about 12 to 16 g/dL in females and 14 to 18 g/dL in males. Hematocrit about 37 to 47 percent in females and 42 to 52 percent in males.

Normal white blood cell and platelet counts

White blood cells about 5,000 to 10,000/mm3. Platelets about 150,000 to 400,000/mm3.

Normal fasting blood glucose

About 70 to 100 mg/dL. Below about 70 mg/dL is hypoglycemia.

Adult urine output that must be reported

Less than about 30 mL per hour.

Recognizing and Reporting Abnormal Findings

Signs of low potassium

Muscle weakness, leg cramps, decreased deep tendon reflexes, hypoactive or absent bowel sounds with abdominal distension, and irregular heartbeat.

Signs of high potassium

Muscle weakness, numbness and tingling, and dangerous cardiac rhythm changes. Report a level above 5.0 mEq/L, and treat a level above 5.5 mEq/L as urgent.

Signs of low calcium

Tingling around the mouth and in the fingertips, muscle twitching and cramps, positive Chvostek sign (facial twitch when the facial nerve is tapped), and positive Trousseau sign (hand spasm when the blood pressure cuff is inflated).

Signs of low blood glucose and the immediate action for a conscious client

Shakiness, sweating, fast heartbeat, hunger, irritability, and confusion. Give about 15 grams of a fast-acting carbohydrate, recheck the glucose in 15 minutes, and report.

Findings that suggest bleeding after a procedure

Rising heart rate, falling blood pressure, restlessness, cool clammy skin, pallor, increasing pain, expanding bruising or swelling at the site, and saturated dressings. Report right away.

Respiratory rate that requires reporting in a client receiving opioids

Below 12 breaths per minute, especially with increasing sedation. Stop further opioid dosing, stimulate the client, apply oxygen, and report immediately.

Heart rate that requires holding a dose and reporting for digoxin or a beta blocker

An adult apical pulse below 60 beats per minute counted for a full minute. Hold the dose per policy and report.

Signs of digoxin toxicity to report

Loss of appetite, nausea and vomiting, visual changes such as yellow-green halos, slow heart rate, and irregular rhythm.

Signs of fluid overload during intravenous therapy

Shortness of breath, crackles in the lungs, jugular vein distension, bounding pulse, rising blood pressure, and rapid weight gain. Slow the infusion to a keep-open rate, raise the head of the bed, and report.

Signs of dehydration

Thirst, dry mucous membranes, poor skin turgor, concentrated dark urine, low urine output, weight loss, rising heart rate, and orthostatic dizziness.

Signs of a possible deep vein thrombosis and what not to do

Swelling, warmth, redness, and pain in one calf or leg. Do not massage or exercise the leg. Report immediately.

Signs of a wound infection

Increasing redness, warmth, swelling, purulent drainage, increasing pain after the first days, foul odor, and fever.

Signs that a wound may be separating

A sudden gush of serosanguineous drainage and the client's report that something "gave way" at the incision. Report at once.

What a change in level of consciousness means

A new decrease in alertness, orientation, or responsiveness is one of the most important early warning signs of a serious problem and is always reported promptly.

Intravenous Site and Transfusion Safety

Signs of intravenous infiltration

Swelling, coolness, pallor at the site, and a slowed infusion rate. Stop the infusion, remove the catheter, and elevate the extremity.

Signs of phlebitis

Redness, warmth, tenderness, and a firm cord-like vein. Discontinue the site and report. Do not massage the area.

First action when a transfusion reaction is suspected

Stop the transfusion immediately, keep the vein open with normal saline using new tubing, then take vital signs and notify the registered nurse, provider, and blood bank.

Findings that suggest a serious transfusion reaction

Fever, chills, low back or flank pain, hives and itching, shortness of breath, wheezing, hypotension, dark or red urine, and a sense of impending doom.

How long the nurse stays with the client at the start of a transfusion

The first 15 minutes, because most severe reactions begin early. The rate is started slowly, and normal saline is the only compatible solution.

Pre-Procedure and Post-Procedure Care

Standard pre-procedure checks

Confirm identity with two identifiers, verify that consent is signed and on the chart, verify nothing by mouth status, check allergies, obtain baseline vital signs, have the client void when the procedure involves the abdomen or pelvis, and remove dentures, jewelry, and prostheses as directed.

Care after any procedure that numbs the throat, such as endoscopy or bronchoscopy

Keep the client nothing by mouth until the gag reflex returns, position on the side while still sedated, and monitor the airway.

Warning signs of perforation after endoscopy or colonoscopy

Severe or worsening abdominal or chest pain, abdominal distension and rigidity, fever, fast heart rate, and low blood pressure. Report immediately.

Positioning and preparation for a lumbar puncture

Have the client void first, then position side-lying with knees drawn toward the abdomen and chin tucked, or sitting and leaning forward over a table. Afterward keep the client flat as ordered, encourage fluids, and report headache or leakage at the site.

Positioning for a thoracentesis and the main complication afterward

Sitting upright and leaning forward over a bedside table with arms supported, holding still without coughing during needle insertion. Watch for pneumothorax, shown by sudden shortness of breath, chest pain, and diminished breath sounds on that side.

Care before and after paracentesis

Have the client void immediately before, position upright or with the head of the bed elevated, measure abdominal girth and weight before and after, and watch for hypotension and dizziness from fluid shifts afterward.

Positioning after a liver biopsy

On the right side with a pillow or rolled towel against the site to apply pressure, with bed rest, watching for bleeding and for pain in the right shoulder.

Care after a cardiac catheterization

Bed rest with the affected leg straight for the ordered time, frequent checks of the site for bleeding or swelling, checks of the pulse, color, temperature, and sensation below the site, cardiac monitoring, and fluids to flush the contrast.

Teaching after a barium study

Drink extra fluids, take the ordered laxative, expect chalky white stools for a few days, and report if no stool occurs.

How to perform and read a tuberculin skin test

Inject intradermally to raise a small wheal, do not massage the site, and read the area of firm induration, not redness, at 48 to 72 hours.

How to collect a 24-hour urine specimen correctly

Discard the first voiding to start the clock, save every voiding for 24 hours, keep the specimen chilled as required, and have the client void at the exact end time to include that specimen. If any voiding is lost, the collection must start over.

What to report before a magnetic resonance imaging study

Any implanted or retained metal, including pacemakers, aneurysm clips, cochlear implants, and metal fragments, plus severe claustrophobia and kidney disease if contrast is planned.

Prevention and Safety

Interventions that prevent atelectasis and pneumonia after surgery

Incentive spirometry, deep breathing and coughing with incision splinting, early ambulation, adequate pain control, and repositioning.

Bleeding precautions for a client with a low platelet count

Electric razor, soft toothbrush, no rectal temperatures or suppositories, avoid intramuscular injections when possible, prolonged pressure after venipuncture, avoid aspirin and nonsteroidal anti-inflammatory drugs, and prevent falls.

Infection precautions for a client with a very low white blood cell count

Strict hand hygiene, limit exposure to people who are ill, avoid fresh flowers and standing water, follow facility policy on food handling, avoid invasive procedures when possible, and report any temperature elevation immediately.

Interventions that prevent falls

Bed in the lowest position with wheels locked, call light and personal items within reach, nonskid footwear, adequate lighting, assistance with the first standing after bed rest, and evaluation of orthostatic changes.

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