Nursing Fundamentals
Insulin onset/peak for regular (short-acting)
Prioritize physiologic needs first (airway, breathing, circulation, food, water, shelter), followed by safety, love/belonging, esteem, and self-actualization. Pain typically supersedes psychosocial needs unless life-threatening.
Muscle weakness, fatigue, paresthesias, nausea, palpitations, and characteristic ECG changes: peaked T waves, widened QRS, prolonged PR interval, loss of P waves, and eventually sine wave or ventricular fibrillation.
SpO2 measures saturation %, not oxygen content. Severe anemia with normal SpO2 may still cause tissue hypoxia due to low hemoglobin-bound oxygen delivery.
Onset 30–60 min, peak 2–3 hours, duration 5–7 hours. Given subcutaneously; IV regular insulin is used in DKA and hyperglycemic emergencies.
Nursing Fundamentals
Angle for intradermal injection
5 to 15 degrees with bevel up; inject 0.1 mL to produce a wheal. Used for TB (PPD), allergy, and local anesthesia testing.
P = Pull the pin. A = Aim at the base of the fire. B = Squeeze the handle. S = Sweep side to side across the fire's base until extinguished. Use only on small, contained fires.
Early signs include decreased deep tendon reflexes, flushing, warmth, drowsiness, and slurred speech. Late signs: hypotension, respiratory depression, EKG changes, and cardiac arrest. Antidote: calcium gluconate.
Administer over 2–5 minutes (or per manufacturer) to prevent rapid adverse reactions. Always assess IV patency and patient tolerance during and after administration.
Nursing Fundamentals
Calcium gluconate administration in hyperkalemia: why?
R-Rescue patients from danger; A-Activate fire alarm and call for help; C-Contain fire (close doors/windows); E-Evacuate/Extinguish if safe using PASS technique (Pull, Aim, Squeeze, Sweep).
Calcium gluconate stabilizes cardiac membranes and prevents fatal arrhythmias within minutes but does NOT lower potassium. Duration 30-60 minutes; must follow with actual K-reducing therapies (insulin, kayexalate).
Normal serum magnesium: 1.5–2.5 mEq/L (or 1.7–2.4 mg/dL). Critical for muscle and nerve function, cardiac rhythm stability, and ATP production. Monitor in patients on diuretics, with renal failure, or receiving amphotericin B or cisplatin.
Use one-handed scoop method: place cap on flat surface, slide needle into cap with one hand, then secure. Never recap using two hands to prevent needlestick injury.
Nursing Fundamentals
Normal adult MAP (mean arterial pressure) value and calculation?
Prioritize airway, breathing, circulation threats first. Among four patients, see the one with airway obstruction, stridor, or cyanosis before the patient with pain, anxiety, or scheduled procedures. Document rationale for any prioritization decisions.
Approximately 70–130 beats per minute. Heart rate decreases with age: toddlers 100–160, preschoolers 80–140, school-age 70–120. Document rate, rhythm, and any irregularities.
5 to 15 degrees with bevel up; inject 0.1 mL to produce a wheal. Used for TB (PPD), allergy, and local anesthesia testing.
Normal MAP is 70-100 mmHg. Calculation: MAP = (SBP + 2×DBP) ÷ 3. MAP reflects perfusion pressure to organs; values
Nursing Fundamentals
Tympanic vs. oral temperature comparison?
Sharps containers should be replaced when two-thirds (2/3) full. Overfilling increases needlestick injury risk. Containers must be puncture-resistant, leak-proof, and labeled with biohazard symbol.
Head-to-toe assessment, full history (AMPLE: Allergies, Medications, Past medical, Last meal, Events), vital signs, diagnostics after primary survey is stable.
Hypercalcemia produces stones (kidney), bones (pain), groans (abdominal), and psychiatric overtones (confusion). ECG shows shortened QT interval. Severe cases cause cardiac arrhythmias. Causes include hyperparathyroidism, malignancy with bone metastases, and prolonged immobilization.
Tympanic readings average 0.3–0.5 °C (0.5–1.0 °F) higher than oral. Use the same ear consistently; contraindicated with cerumen impaction or otitis media.
Nursing Fundamentals
Aspiration before IM injection
Required for all IM injections to verify needle is not in a blood vessel. If blood returns, withdraw, discard, and prepare new injection. Exceptions are uncommon.
Clarification is asking the patient to restate or elaborate on a vague or confusing statement, e.g., 'What do you mean when you say you feel unwell?' It ensures accurate understanding and demonstrates active listening.
Stop the transfusion immediately, maintain IV patency with normal saline, notify the physician, and assess vital signs. Do not discard the blood bag; send it and patient sample to the blood bank for analysis.
Offering self: 'I'll sit with you'—conveys presence and availability. Silence: allows patient time to organize thoughts, conveys acceptance, and reduces anxiety. Both are nonverbally therapeutic. Avoid premature advice or reassurance ('Everything will be fine').
Nursing Fundamentals
PASS technique for fire extinguisher operation
SpO2 measures saturation %, not oxygen content. Severe anemia with normal SpO2 may still cause tissue hypoxia due to low hemoglobin-bound oxygen delivery.
Sweating, tremor, tachycardia, hunger, confusion, irritability, and possible seizures. Treat immediately with 15 g fast-acting carbohydrate; recheck in 15 minutes.
P-A-S-S: Pull the pin, Aim at the base of the fire, Squeeze the handle, Sweep side to side across the fire's base. Only use on small, contained fires; otherwise evacuate and wait for the fire department.
97.5°F to 99.5°F (average 98.6°F). Values above 100.4°F typically indicate fever; hypothermia is below 95°F. Rectal readings run ~0.5–1°F higher, axillary ~0.5–1°F lower.
Nursing Fundamentals
Phlebitis scale grades
Anion gap = Na − (Cl + HCO3). Normal 8-16 mEq/L. Elevated gap suggests metabolic acidosis from MUDPILES: methanol, uremia, DKA, propylene glycol, isoniazid/iron, lactic acidosis, ethylene glycol, salicylates.
If a provider's order seems unsafe, the nurse should voice concern twice. If disregarded, escalate up the chain of command. Protects patients and supports nurse's ethical duty to advocate.
0: no symptoms. 1+: mild pain, redness. 2+: pain, redness, swelling. 3+: palpable cord. 4+: pain, redness, swelling, palpable venous cord >1 inch, purulence.
Heparin IV push is contraindicated; always administer via continuous infusion pump. Avoid IM injections to prevent hematoma. Monitor aPTT levels (target 1.5-2.5× normal) and platelet counts for HIT.
Nursing Fundamentals
Therapeutic communication: clarifying technique purpose?
Frequent rounding, bed in lowest position with brakes locked, call light within reach, non-slip footwear, adequate lighting, clutter-free environment, orient to room, scheduled toileting.
Right task, right circumstance, right person (competent), right direction/communication, and right supervision/evaluation. Delegator retains accountability; delegate is responsible for completing the task correctly. Never delegate nursing judgment, teaching, or assessment to UAPs.
Tympanic readings average 0.3–0.5 °C (0.5–1.0 °F) higher than oral. Use the same ear consistently; contraindicated with cerumen impaction or otitis media.
Clarifying verifies the nurse's understanding and prompts the patient to elaborate. Example: 'When you say you're feeling tired, can you describe what that feels like?' Prevents misinterpretation of vague statements.
Nursing Fundamentals
Injection site rotation pattern for insulin
Apical pulse is preferred for infants and young children, patients with irregular rhythms, those on cardiac medications, and when radial pulse is difficult to palpate accurately.
Rotate within same anatomical region for 1 week before moving to new site. Avoid using same spot twice within 2 weeks to prevent lipohypertrophy and erratic absorption.
Head-to-toe assessment, full history (AMPLE: Allergies, Medications, Past medical, Last meal, Events), vital signs, diagnostics after primary survey is stable.
Physiologic needs first (airway, breathing, circulation, nutrition, elimination), then safety, then love/belonging, esteem, and finally self-actualization. Guides basic care ordering.
Nursing Fundamentals
SBAR communication format components?
S = Situation (who, where, current problem). B = Background (relevant history, diagnosis, allergies). A = Assessment (vital signs, clinical findings, your interpretation). R = Recommendation (what you need or suggest).
Offering self: 'I'll sit with you'—conveys presence and availability. Silence: allows patient time to organize thoughts, conveys acceptance, and reduces anxiety. Both are nonverbally therapeutic. Avoid premature advice or reassurance ('Everything will be fine').
Sharps containers should be replaced when two-thirds (2/3) full. Overfilling increases needlestick injury risk. Containers must be puncture-resistant, leak-proof, and labeled with biohazard symbol.
Finger (index or middle) is standard. Use earlobe for poor perfusion. Avoid toes in peripheral vascular disease. Wait 10–30 seconds for stable reading; check perfusion and assess for motion artifact.
Nursing Fundamentals
Maslow priority example in nursing care
Ventrogluteal site is preferred for IM injections because: thicker gluteal muscle layer provides better absorption, less subcutaneous fat, avoids major nerves and blood vessels, and accommodates up to 3 mL safely. Use the 'V' formed by index/middle fingers on greater trochanter and ASIS.
Onset 30–60 min, peak 2–3 hours, duration 5–7 hours. Given subcutaneously; IV regular insulin is used in DKA and hyperglycemic emergencies.
Administer furosemide in the morning to avoid nocturia and sleep disruption. Monitor potassium levels (hypokalemia risk), daily weights, intake/output, and blood pressure for orthostatic changes.
Apply Maslow's hierarchy: physiological needs (airway, breathing, circulation, nutrition, elimination) take priority over safety, then love/belonging, esteem, and self-actualization. Example: administer oxygen and pain medication before addressing anxiety or spiritual concerns.
Nursing Fundamentals
Normal adult resting respiratory rate
12 to 20 breaths per minute. Bradypnea is below 12; tachypnea is above 20. Assess rate, depth, and rhythm for one full minute.
Approximately 70–130 beats per minute. Rates vary by age: newborns 100–160, toddlers 80–130, preschoolers 80–120. Always compare to age-specific norms.
Normal MAP is 70-100 mmHg. Calculation: MAP = (SBP + 2×DBP) ÷ 3. MAP reflects perfusion pressure to organs; values
Finger, toe, or earlobe. Avoid fingers with nail polish, artificial nails, edema, poor perfusion, or excessive movement. Earlobe reflects central perfusion best.
Nursing Fundamentals
Components of the Morse Fall Scale?
Clusters of quick, shallow breaths alternating with irregular periods of apnea. Associated with increased intracranial pressure or brainstem injury affecting respiratory centers.
Wear goggles or face shield whenever splashes or sprays of blood, body fluids, secretions, or chemicals are possible (e.g., suctioning, wound irrigation, deliveries, surgical procedures). Standard precautions also require them during aerosol-generating procedures.
Morse Fall Scale assesses: history of falling, secondary diagnosis, ambulatory aid, IV/heparin lock, gait, mental status. Scores ≥45 indicate high fall risk requiring targeted interventions.
Right task, right circumstance, right person, right direction/communication, and right supervision/evaluation. RN must verify competency of assistive personnel before delegating.
Nursing Fundamentals
First nursing action for suspected transfusion reaction?
Cheyne-Stokes involves progressively deeper breathing followed by gradual apnea cycles. Seen in increased ICP, brainstem stroke, heart failure, or impending death; indicates serious neurological compromise.
Stop the transfusion immediately, maintain IV patency with normal saline, notify the physician, and assess vital signs. Do not discard the blood bag; send it and patient sample to the blood bank for analysis.
NPH onset 1–2 hours, peak 4–12 hours (typically 6–10), duration 18–24 hours. Only insulin that can be mixed with regular insulin. Given subcut; can cause hypoglycemia, especially at peak time.
Right patient, right drug, right dose, right route, right time, and right documentation. Many institutions add right reason and right response.
Nursing Fundamentals
What does an MSDS (SDS) sheet provide?
Safety Data Sheets provide chemical hazard information: identification, physical data, fire/explosion risks, reactivity, health hazards, protective equipment, spill procedures, and first-aid measures.
Cool, pale, taut, painful, swollen area around IV site; absent or sluggish blood return. Stop infusion immediately, remove catheter, elevate extremity, apply warm or cold compress per facility protocol, and document.
Tall peaked T waves, widened QRS, prolonged PR interval, and eventual sine-wave pattern. Severe cases require calcium gluconate, insulin/glucose, and dialysis.
Airway/Breathing/Circulation takes priority over Maslow's hierarchy. A patient with acute dyspnea (ABC) is seen before one requesting help with bathing (physiological/safety), even though both are physiologic needs.
Nursing Fundamentals
Five rights of medication administration beyond the basic six?
Orienting patient to room, keeping call light within reach, non-slip footwear, adequate lighting, bed in low position, frequent rounding, clutter-free environment.
Tall peaked T waves, widened QRS, prolonged PR interval, and eventual sine-wave pattern. Severe cases require calcium gluconate, insulin/glucose, and dialysis.
Sharps containers should be replaced when two-thirds (2/3) full. Overfilling increases needlestick injury risk. Containers must be puncture-resistant, leak-proof, and labeled with biohazard symbol.
Beyond patient, drug, dose, route, time, documentation: the additional 'rights' include right reason/indication, right response (monitor therapeutic effect), and right to refuse (informed consent).
Nursing Fundamentals
Signs of hypercalcemia
Hypercalcemia produces stones (kidney), bones (pain), groans (abdominal), and psychiatric overtones (confusion). ECG shows shortened QT interval. Severe cases cause cardiac arrhythmias. Causes include hyperparathyroidism, malignancy with bone metastases, and prolonged immobilization.
The Morse Fall Scale scores history of falling, secondary diagnosis, ambulatory aid, IV/heel lock, gait, and mental status. Score ≥45 indicates high fall risk.
NPH insulin onset 1–2 hours, peak 4–12 hours, duration 18–24 hours. Cloudy appearance; roll vial gently to mix before drawing up dose.
Bounding pulse, elevated BP, dyspnea, crackles, JVD, edema, weight gain, and S3 heart sound. Notify provider; restrict fluids and consider diuretics.
Nursing Fundamentals
Three checks of medication administration?
Wear goggles or face shield during procedures likely to generate splashes or sprays of blood, body fluids, secretions, or excretions (e.g., suctioning, wound irrigation, central line insertion assistance).
Clarification is asking the patient to restate or elaborate on a vague or confusing statement, e.g., 'What do you mean when you say you feel unwell?' It ensures accurate understanding and demonstrates active listening.
IV calcium gluconate (cardiac membrane stabilizer) within minutes, followed by insulin with dextrose (shifts K+ into cells), then sodium bicarbonate if acidotic, and finally Kayexalate or dialysis to remove potassium.
Check 1: When pulling medication from storage. Check 2: When preparing or measuring dose. Check 3: At the bedside before giving to patient. Verifies right drug, dose, route, patient, time, and documentation.
Nursing Fundamentals
Extravasation of vesicant chemotherapy: nursing action?
36.1–37.2 °C (97.0–99.0 °F). Values above 38.0 °C (100.4 °F) define fever; below 35.0 °C (95.0 °F) defines hypothermia requiring intervention.
0: no symptoms. 1+: mild pain, redness. 2+: pain, redness, swelling. 3+: palpable cord. 4+: pain, redness, swelling, palpable venous cord >1 inch, purulence.
Stop infusion immediately, leave needle in place, aspirate residual drug, notify provider, administer antidote per protocol, apply cold (or warm for vinca) compress, and document. Surgical consult may be needed.
Stable patients with routine tasks: vital signs, hygiene, toileting, feeding (non-aspiration risk), ambulation, intake/output measurement, and documentation of completed tasks.
Nursing Fundamentals
Insulin onset/peak for long-acting glargine (Lantus)?
Situation (what is happening), Background (relevant history), Assessment (your clinical impression), Recommendation (what you need). Standardizes nurse-to-provider handoffs.
Before patient contact, before aseptic task, after body fluid exposure risk, after patient contact, and after contact with patient surroundings.
Abdomen (preferred—fastest absorption), followed by upper arms, thighs, and buttocks. Rotate within a site; keep 1 inch from umbilicus and 2 inches from scars.
Glargine onset 1 hour, NO pronounced peak, duration 24 hours. Given once or twice daily subcut. Cannot be mixed with other insulins. Use only clear, colorless insulin syringe; do not confuse with NPH.
Nursing Fundamentals
RACE protocol for fire response
Phase I: first clear tapping sound = systolic. Phase IV: muffled sound. Phase V: disappearance = diastolic. Record both phase IV and V when sounds remain to zero for accurate pediatric assessment.
R-Rescue patients from danger; A-Activate fire alarm and call for help; C-Contain fire (close doors/windows); E-Evacuate/Extinguish if safe using PASS technique (Pull, Aim, Squeeze, Sweep).
Cheyne-Stokes involves progressively deeper breathing followed by gradual apnea cycles. Seen in increased ICP, brainstem stroke, heart failure, or impending death; indicates serious neurological compromise.
Insulin shock: hypoglycemia—tachycardia, sweating, tremor, confusion, seizures, low glucose (250.
Nursing Fundamentals
Neutropenic precautions for immunocompromised patients?
Stable patients have predictable outcomes and established care plans; UAPs may assist. Unstable patients require ongoing assessment and clinical judgment—must be cared for directly by RN.
Use observational tools: PAINAD (Pain Assessment in Advanced Dementia), Abbey Pain Scale, or DOLOPLUS-2. These assess breathing, vocalization, facial expression, body language, and consolability instead of self-report.
Restlessness, thirst, dry mucous membranes, decreased skin turgor (tenting), tachycardia, hypotension, weak/thready pulse, decreased urine output (
Protective isolation: private room, positive pressure if available, no fresh flowers/plants, no fresh fruits/raw vegetables, strict handwashing, screen visitors for illness, avoid invasive procedures when possible.
Nursing Fundamentals
Therapeutic communication: offering general leads
Physiologic needs first (airway, breathing, circulation, nutrition, elimination), then safety, then love/belonging, esteem, and finally self-actualization. Guides basic care ordering.
An SDS provides chemical hazard information: identity, physical/health hazards, protective measures, spill handling, first aid, and storage. OSHA requires SDS for every hazardous chemical in the workplace; nurses must review before handling chemotherapeutic or cleaning agents.
Unopened vials stored refrigerated; in-use vials at room temperature up to 28 days. Never freeze; never use past expiration. Two nurses must verify insulin type and dose before administration.
Encourages patient to continue sharing without leading or directing. Example: 'Tell me more about that' or 'And then what happened?' Useful for exploring feelings and concerns.
Nursing Fundamentals
Febrile temperature threshold (oral) in adults?
Approximately 36.1°C to 37.2°C (97.0°F to 99.0°F). Average is 37.0°C (98.6°F). Values above 38.0°C (100.4°F) typically indicate fever.
≥38.0 °C (100.4 °F). This is the standard fever definition per CDC; 38.0–38.9 °C is low-grade, 39.0–40.0 °C is moderate, >40.0 °C is high fever.
P: Provocation/Palliation, Q: Quality, R: Region/Radiation, S: Severity (0–10), T: Timing (onset, duration, frequency). Guides comprehensive pain evaluation.
Use stethoscope at 5th intercostal space, midclavicular line (PMI). Count for 60 seconds (especially if irregular). Document rate, rhythm, and any murmurs.
Nursing Fundamentals
Pain rating scales appropriate for cognitively impaired adults?
Head-to-toe assessment, full history (AMPLE: Allergies, Medications, Past medical, Last meal, Events), vital signs, diagnostics after primary survey is stable.
Finger (index or middle) is standard. Use earlobe for poor perfusion. Avoid toes in peripheral vascular disease. Wait 10–30 seconds for stable reading; check perfusion and assess for motion artifact.
Use PAINAD or FLACC tools that rely on observable behaviors (facial expression, body language, vocalization) rather than self-report for those unable to communicate.
Used when patient statement is vague or unclear. Restating or questioning to verify understanding, e.g., 'I'm not sure what you mean by feeling bad—can you describe what that feels like?'
Nursing Fundamentals
Signs of warfarin (Coumadin) toxicity
Once aware, patients may alter breathing. Count respirations immediately after assessing pulse, while still holding the wrist, to obtain an accurate baseline unaffected by conscious control.
'This is RN Smith on Unit 4. I'm calling about Mr. Jones in Room 312, a 68-year-old male admitted yesterday for pneumonia. He is complaining of increased shortness of breath over the past hour.'
Unusual bruising, petechiae, epistaxis, bleeding gums, blood in urine or stool, prolonged bleeding from cuts, severe headache or abdominal pain indicating internal bleeding.
Right patient, right drug, right dose, right route, right time, and right documentation. Many institutions add right reason and right response.
Nursing Fundamentals
Therapeutic communication technique: clarification?
Axillary readings average 0.5–1.0 °C lower than oral. Considered least reliable; reserved for oral-contraindicated situations. Document site clearly.
Prioritize physiologic needs first (airway, breathing, circulation, food, water, shelter), followed by safety, love/belonging, esteem, and self-actualization. Pain typically supersedes psychosocial needs unless life-threatening.
Clarification is asking the patient to restate or elaborate on a vague or confusing statement, e.g., 'What do you mean when you say you feel unwell?' It ensures accurate understanding and demonstrates active listening.
Deep, rapid, labored breathing (rate >20, deep). Compensatory response to metabolic acidosis, commonly diabetic ketoacidosis (DKA). Body attempts to blow off CO2.
Nursing Fundamentals
Pulse pressure calculation and significance?
LPNs cannot perform initial patient assessments, develop or modify nursing care plans, evaluate outcomes, administer IV push medications (in most states), handle blood products, or care for unstable patients requiring complex judgments.
Early signs include decreased deep tendon reflexes, flushing, warmth, drowsiness, and slurred speech. Late signs: hypotension, respiratory depression, EKG changes, and cardiac arrest. Antidote: calcium gluconate.
Systolic minus diastolic. Normal 30–50 mmHg. Wide (>60) suggests aortic regurgitation, aneurysm, or hyperthyroidism. Narrow (
Pull the pin, Aim at base of fire, Squeeze the handle, Sweep side to side. Used for operating a fire extinguisher during fire emergency response.
Nursing Fundamentals
Two-challenge rule for patient safety advocacy?
Nausea, vomiting, anorexia, visual disturbances (yellow/green halos), bradycardia, and dysrhythmias. Hypokalemia increases toxicity risk; check level and apical pulse.
DVT findings: unilateral leg pain/tenderness, swelling, warmth, redness, and possibly a palpable cord. Homan sign (calf pain on dorsiflexion) is unreliable. Confirm with duplex ultrasound. Treatment includes anticoagulation, ambulation, and compression stockings; avoid prolonged immobility.
If a provider's order seems unsafe, the nurse should voice concern twice. If disregarded, escalate up the chain of command. Protects patients and supports nurse's ethical duty to advocate.
Ventrogluteal site is preferred for adults because it is away from major nerves and blood vessels, has consistent thin fat layer, accommodates up to 3 mL, and uses gluteus medius muscle for reliable absorption.
Nursing Fundamentals
Components of a focused assessment?
Limited to the specific body system or problem relevant to current concern. Includes targeted history questions, focused physical exam, and review of related systems only.
Calcium gluconate stabilizes cardiac membranes and prevents fatal arrhythmias within minutes but does NOT lower potassium. Duration 30-60 minutes; must follow with actual K-reducing therapies (insulin, kayexalate).
Biographical data, reason for seeking care (chief complaint), present illness history (PQRST or OLD CARTS), and past history including family, psychosocial, and review of systems.
NPH onset 1–2 hours, peak 4–12 hours (typically 6–10), duration 18–24 hours. Only insulin that can be mixed with regular insulin. Given subcut; can cause hypoglycemia, especially at peak time.
Nursing Fundamentals
Why count respirations without patient awareness?
Orienting patient to room, keeping call light within reach, non-slip footwear, adequate lighting, bed in low position, frequent rounding, clutter-free environment.
Phase I: first clear tapping sound = systolic. Phase IV: muffled sound. Phase V: disappearance = diastolic. Record both phase IV and V when sounds remain to zero for accurate pediatric assessment.
Awareness alters breathing pattern. Count immediately after palpating pulse while still holding the wrist, appearing to continue pulse assessment.
Private room, no fresh flowers/plants, no raw fruits/vegetables, avoid crowds/ill visitors, strict hand hygiene, no fresh-cut flowers, dedicated equipment, and mask when leaving room.
Nursing Fundamentals
Maslow's hierarchy applied to nursing prioritization?
LPNs can administer oral, IM, SQ, and intradermal medications in most states. They typically cannot administer IV push medications, blood products, or chemotherapy—varies by state board regulations.
Prioritize physiologic needs (airway, breathing, circulation, nutrition, elimination, shelter) before safety, then love/belonging, esteem, and self-actualization. Pain and physiologic stability supersede psychosocial concerns.
Frequent rounding, bed in lowest position with brakes locked, call light within reach, non-slip footwear, adequate lighting, clutter-free environment, orient to room, scheduled toileting.
Private room or cohort; wear surgical mask within 3 feet (1 meter) of patient. Used for influenza, pertussis, meningococcal disease, mumps, rubella.
Nursing Fundamentals
When is apical pulse the preferred assessment site?
Safety Data Sheets provide chemical hazard information: identification, physical data, fire/explosion risks, reactivity, health hazards, protective equipment, spill procedures, and first-aid measures.
Apical pulse is preferred for infants and young children, patients with irregular rhythms, those on cardiac medications, and when radial pulse is difficult to palpate accurately.
Systolic below 120 mmHg and diastolic below 80 mmHg define normal. Elevated: 120–129/
Right task, right circumstance, right person, right direction/communication, and right supervision/evaluation. RN must verify competency of assistive personnel before delegating.
Nursing Fundamentals
Numeric pain scale (0–10) interpretation?
Purposeful silence allows the patient time to process thoughts, organize responses, and reflect. It conveys acceptance and presence. Avoid prolonged awkward silence; use it intentionally to encourage patient sharing.
0 = no pain; 1–3 mild; 4–6 moderate; 7–10 severe. Acceptable post-op pain level generally ≤3 at rest, ≤5 with activity. Document location, quality, timing.
Stop infusion immediately, remove catheter, elevate extremity, apply warm (or cool per facility policy) compresses, and document. Do not flush; notify provider.
Remove gloves first (most contaminated), perform hand hygiene, then remove goggles/face shield, gown, and finally mask. Perform hand hygiene after each step.
Nursing Fundamentals
IV push medication dilution and time standard?
Stable patients with predictable outcomes: vital signs, hygiene, toileting, ambulation, intake/output measurement, and feeding (not aspiration-risk patients). RN retains responsibility for assessment, teaching, and evaluation.
Most IV push medications should be administered over 1-2 minutes minimum, diluted per manufacturer. Rapid administration causes venous irritation, arrhythmias, or toxicity. Always reconstitute and follow ISMP guidelines.
Cyclic pattern of gradually deepening then shallowing respirations with apnea periods. Seen in heart failure, stroke, increased ICP, or impending death.
Muscle weakness, cramps, fatigue, constipation, ileus, paresthesias, and ECG changes: flattened T waves, prominent U waves, ST depression, and ventricular dysrhythmias. Seen with diuretics, vomiting, or NG suction.
Nursing Fundamentals
Proper needle recapping technique (if required)
BP cuff inflation obstructs IV flow, causing infusion interruption and possible clotting or backflow of blood into the tubing, risking inaccurate readings and compromised medication delivery.
Clarification is asking the patient to restate or elaborate on a vague or confusing statement, e.g., 'What do you mean when you say you feel unwell?' It ensures accurate understanding and demonstrates active listening.
Use one-handed scoop method: place cap on flat surface, slide needle into cap with one hand, then secure. Never recap using two hands to prevent needlestick injury.
1) Biographic/demographic data, 2) Reason for seeking care (chief complaint), 3) History of present illness (PQRST), 4) Past medical, family, and psychosocial history including review of systems.
Nursing Fundamentals
Axillary temperature reliability?
Biographical data, reason for seeking care (chief complaint), present illness history (PQRST or OLD CARTS), and past history including family, psychosocial, and review of systems.
Axillary readings average 0.5–1.0 °C lower than oral. Considered least reliable; reserved for oral-contraindicated situations. Document site clearly.
Situation (what is happening), Background (relevant history), Assessment (your clinical impression), Recommendation (what you need). Standardizes nurse-to-provider handoffs.
P-A-S-S: Pull the pin, Aim at the base of the fire, Squeeze the handle, Sweep side to side across the fire's base. Only use on small, contained fires; otherwise evacuate and wait for the fire department.