Title: Nursing Fundamentals — LearnCoachAssist

Q: Normal adult oral temperature range in °C
A: 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.

Q: Normal adult resting respiratory rate
A: 12 to 20 breaths per minute. Bradypnea is below 12; tachypnea is above 20. Assess rate, depth, and rhythm for one full minute.

Q: Normal adult resting heart rate
A: 60 to 100 beats per minute. Bradycardia is below 60; tachycardia exceeds 100. Apical pulse should be assessed for one full minute.

Q: Normal adult blood pressure range
A: Systolic below 120 mmHg and diastolic below 80 mmHg define normal. Elevated: 120–129/

Q: Order of vital sign assessment
A: Respirations, pulse, blood pressure, temperature, pain (often remembered by acronym). Respirations are counted first so patient does not consciously alter them.

Q: Best site for infant blood pressure
A: Use the thigh or upper arm with an appropriately sized cuff. Width should be ~40% of limb circumference; length ~80%. Auscultate or use oscillometric device.

Q: What does a pulse oximeter measure?
A: The percentage of hemoglobin saturated with oxygen (SpO2). Normal is 95–100%. It does not measure ventilation, so CO2 retention may still occur.

Q: How long to count a pulse if irregular?
A: Count for one full minute (60 seconds) to detect dysrhythmias and accurately capture rate. Document rhythm, rate, and any deficits.

Q: Orthostatic vital sign procedure
A: Measure BP and pulse with patient supine, then sitting, then standing—waiting 1–3 minutes between positions. Positive if SBP drops ≥20 mmHg or HR rises ≥20 bpm.

Q: Subjective vs. objective data
A: Subjective data is what the patient reports (symptoms, pain, feelings). Objective data is measurable/observable by the nurse (signs, vital signs, lab results).

Q: Components of a focused assessment
A: Includes chief complaint, history of present illness, relevant body system review, vital signs, and targeted physical exam using inspection, palpation, percussion, auscultation.

Q: PQRST pain assessment mnemonic
A: P: Provocation/Palliation, Q: Quality, R: Region/Radiation, S: Severity (0–10), T: Timing (onset, duration, frequency). Guides comprehensive pain evaluation.

Q: Primary nursing survey (ABCDE)
A: Airway with cervical spine control, Breathing, Circulation with hemorrhage control, Disability (neuro status), Exposure/Environmental control. Used in rapid initial assessment.

Q: Fall risk assessment tool example
A: 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.

Q: Universal fall precautions include
A: Orienting patient to room, keeping call light within reach, non-slip footwear, adequate lighting, bed in low position, frequent rounding, clutter-free environment.

Q: Hand hygiene indications (WHO 5 Moments)
A: Before patient contact, before aseptic task, after body fluid exposure risk, after patient contact, and after contact with patient surroundings.

Q: Standard vs. Contact Precautions
A: Standard applies to all patients (hand hygiene, PPE as needed). Contact adds gown and gloves for known or suspected transmissible organisms like MRSA or C. difficile.

Q: Droplet precaution distance
A: Private room or cohort; wear surgical mask within 3 feet (1 meter) of patient. Used for influenza, pertussis, meningococcal disease, mumps, rubella.

Q: Airborne precaution requirements
A: Negative-pressure private room, N95 respirator (or PAPR), and patient wears surgical mask during transport. Used for measles, varicella, and pulmonary TB.

Q: Removing PPE: which item first?
A: Remove gloves first (most contaminated), perform hand hygiene, then remove goggles/face shield, gown, and finally mask. Perform hand hygiene after each step.

Q: Six Rights of Medication Administration
A: Right patient, right drug, right dose, right route, right time, and right documentation. Many institutions add right reason and right response.

Q: Z-track IM injection purpose
A: Prevents tracking of medication through subcutaneous tissue, which can cause staining or irritation. Used for irritating drugs like iron dextran; technique displaces skin laterally.

Q: Aspiration before IM injection
A: 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.

Q: Angle for intradermal injection
A: 5 to 15 degrees with bevel up; inject 0.1 mL to produce a wheal. Used for TB (PPD), allergy, and local anesthesia testing.

Q: Site for subcutaneous insulin injection
A: 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.

Q: Insulin onset/peak for regular (short-acting)
A: Onset 30–60 min, peak 2–3 hours, duration 5–7 hours. Given subcutaneously; IV regular insulin is used in DKA and hyperglycemic emergencies.

Q: Never combine which insulin types?
A: Do not mix glargine (Lantus) or detemir (Levemir) with any other insulin; they are clear long-acting solutions and must be given separately.

Q: Signs of digoxin toxicity
A: Nausea, vomiting, anorexia, visual disturbances (yellow/green halos), bradycardia, and dysrhythmias. Hypokalemia increases toxicity risk; check level and apical pulse.

Q: Hold parameters for digoxin
A: Hold if apical pulse is below 60 bpm in adults or below 70 in children, or if signs of toxicity appear. Notify provider of significant bradycardia.

Q: Signs of hypoglycemia
A: Sweating, tremor, tachycardia, hunger, confusion, irritability, and possible seizures. Treat immediately with 15 g fast-acting carbohydrate; recheck in 15 minutes.

Q: Nursing action for IV infiltration
A: Stop infusion immediately, remove catheter, elevate extremity, apply warm (or cool per facility policy) compresses, and document. Do not flush; notify provider.

Q: Phlebitis scale grades
A: 0: no symptoms. 1+: mild pain, redness. 2+: pain, redness, swelling. 3+: palpable cord. 4+: pain, redness, swelling, palpable venous cord >1 inch, purulence.

Q: Signs of fluid volume overload
A: Bounding pulse, elevated BP, dyspnea, crackles, JVD, edema, weight gain, and S3 heart sound. Notify provider; restrict fluids and consider diuretics.

Q: Normal serum potassium range
A: 3.5 to 5.0 mEq/L. Hypokalemia (5.0) causes peaked T-waves and risk of ventricular arrhythmia.

Q: ECG change of hyperkalemia
A: Tall peaked T waves, widened QRS, prolonged PR interval, and eventual sine-wave pattern. Severe cases require calcium gluconate, insulin/glucose, and dialysis.

Q: First-line treatment for severe hyperkalemia
A: IV calcium gluconate to stabilize cardiac membrane (onset minutes), followed by insulin with dextrose, sodium bicarbonate if acidotic, and potassium-removing therapies.

Q: Normal serum sodium range
A: 135 to 145 mEq/L. Hyponatremia (145) causes thirst, restlessness, and possible coma.

Q: Therapeutic communication technique: restatement
A: Repeating the patient's words back to clarify meaning; encourages continued dialogue without leading or judging. Example: 'You said the pain worsens at night?'

Q: Difference between delegation and assignment
A: Delegation transfers responsibility for a task while retaining accountability for outcomes; assignment distributes work consistent with scope and competence. RNs cannot delegate nursing judgment.

Q: Five rights of delegation
A: Right task, right circumstance, right person, right direction/communication, and right supervision/evaluation. RN must verify competency of assistive personnel before delegating.

Q: Prioritization framework: Maslow
A: Physiologic needs first (airway, breathing, circulation, nutrition, elimination), then safety, then love/belonging, esteem, and finally self-actualization. Guides basic care ordering.

Q: ABC priority example: which patient first?
A: Choose airway, breathing, or circulation threats first. Among four patients, the one with new-onset stridor or SpO2 of 86% takes priority over pain, infection, or anxiety.

Q: SBAR communication format
A: Situation (what is happening), Background (relevant history), Assessment (your clinical impression), Recommendation (what you need). Standardizes nurse-to-provider handoffs.

Q: Normal adult oral temperature range in °F?
A: 97°F to 99°F (36.1°C to 37.2°C). Values above 100.4°F (38°C) indicate fever; below 95°F (35°C) indicates hypothermia requiring intervention.

Q: Pulse pressure calculation and significance
A: Pulse pressure = systolic minus diastolic. Normal is 30–50 mmHg. Widened (>60) suggests aortic regurgitation; narrowed (

Q: When is apical pulse the preferred assessment site?
A: 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.

Q: Normal pediatric (1–10 yr) heart rate range?
A: 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.

Q: Biot respirations description and clinical significance
A: Clusters of quick, shallow breaths alternating with irregular periods of apnea. Associated with increased intracranial pressure or brainstem injury affecting respiratory centers.

Q: Kussmaul respirations description and significance
A: Deep, rapid, labored breathing (rate >20, deep). Compensatory response to metabolic acidosis, commonly diabetic ketoacidosis (DKA). Body attempts to blow off CO2.

Q: Cheyne-Stokes respirations pattern and cause
A: Cyclic pattern of gradually deepening then shallowing respirations with apnea periods. Seen in heart failure, stroke, increased ICP, or impending death.

Q: Best site for pulse oximeter probe placement
A: Finger, toe, or earlobe. Avoid fingers with nail polish, artificial nails, edema, poor perfusion, or excessive movement. Earlobe reflects central perfusion best.

Q: Pain rating scales appropriate for cognitively impaired adults?
A: Use PAINAD or FLACC tools that rely on observable behaviors (facial expression, body language, vocalization) rather than self-report for those unable to communicate.

Q: Components of a comprehensive health history (4 sections)
A: 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.

Q: Inspection vs. palpation order in physical assessment
A: Inspect first, then palpate, then percuss, then auscultate. Exception: abdominal assessment follows the order inspect, auscultate, percuss, palpate to avoid altering bowel sounds.

Q: RACE protocol for fire response
A: 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).

Q: PASS technique operation
A: 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.

Q: What does MSDS (SDS) sheet provide?
A: Safety Data Sheet details chemical hazards, handling, storage, spill management, first aid, and personal protective equipment required for hazardous substances.

Q: Proper needle recapping technique (if required)
A: 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.

Q: Sharps container fill level safety rule
A: Replace sharps container when 3/4 full or at the fill line. Overfilling increases needlestick injury risk. Never force items into an overfull container.

Q: Droplet precaution PPE requirements
A: Surgical mask within 3 feet (some guidelines 6 feet) of patient. Perform hand hygiene, wear gown and gloves if contact with secretions likely. Private room preferred but not required.

Q: Diseases requiring airborne precautions
A: Measles, varicella (chickenpox), disseminated varicella zoster, and pulmonary or laryngeal tuberculosis. Requires N95 respirator and negative-pressure isolation room.

Q: Neutropenic precautions for immunocompromised patients
A: 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.

Q: Enteric (contact) precautions indications
A: Used for C. difficile, norovirus, rotavirus, and other fecal-oral pathogens. Requires soap and water handwashing (alcohol does not kill spores) and contact PPE.

Q: Eye/face protection PPE indications
A: Wear during procedures likely to generate splashes or sprays of blood, body fluids, secretions, or excretions (suctioning, wound irrigation, airway management, surgery).

Q: Order of donning PPE
A: 1) Hand hygiene, 2) Gown, 3) Mask/respirator, 4) Goggles or face shield, 5) Gloves last. This sequence prevents contamination of face and mucous membranes.

Q: Three checks of medication administration
A: Check 1: when reaching for medication. Check 2: comparing to MAR after retrieval. Check 3: at bedside before administration. Combined with 6 rights ensures safety.

Q: PRN medication documentation requirements
A: Document medication name, dose, time given, reason for administration, patient response, and effectiveness within 30–60 minutes. Pain reassessment is essential documentation.

Q: IM injection site selection: ventrogluteal advantages
A: Ventrogluteal site is preferred for adults: no major nerves or blood vessels, well-developed muscle, thinner subcutaneous layer, safer than dorsogluteal for all ages.

Q: Insulin onset/peak for NPH (intermediate-acting)
A: 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.

Q: Insulin onset/peak for long-acting insulin glargine (Lantus)
A: Onset 1 hour, NO pronounced peak (relatively constant), duration 24+ hours. Clear appearance; do NOT mix with other insulins in same syringe.

Q: Injection site rotation pattern for insulin
A: 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.

Q: Signs of warfarin (Coumadin) toxicity
A: Unusual bruising, petechiae, epistaxis, bleeding gums, blood in urine or stool, prolonged bleeding from cuts, severe headache or abdominal pain indicating internal bleeding.

Q: Antidote for warfarin overdose
A: Vitamin K1 (phytonadione) reverses warfarin effects. For severe/life-threatening bleeding, give vitamin K plus fresh frozen plasma (FFP) or prothrombin complex concentrate (PCC).

Q: Signs of heparin-induced thrombocytopenia (HIT)
A: Platelet count drops >50% from baseline, typically 5–10 days after heparin initiation. Paradoxical thrombosis (clots) despite low platelets. Stop heparin immediately and notify provider.

Q: IV push medication administration over what duration
A: Administer over 2–5 minutes (or per manufacturer) to prevent rapid adverse reactions. Always assess IV patency and patient tolerance during and after administration.

Q: Signs of hypokalemia on ECG
A: Flat or inverted T waves, presence of U waves, ST segment depression, and premature ventricular contractions. Severe cases may cause life-threatening arrhythmias.

Q: Normal serum magnesium range
A: 1.6 to 2.6 mEq/L (or 0.7–1.1 mmol/L). Magnesium deficit often coexists with hypokalemia and hypocalcemia; replacement requires careful monitoring of reflexes.

Q: First-line treatment for symptomatic severe hypocalcemia
A: IV calcium gluconate (preferred peripherally) or calcium chloride (central line required). Administer slowly while monitoring cardiac rhythm; calcium can cause tissue necrosis if extravasates.

Q: SBAR handoff report elements
A: Situation (patient, location, problem), Background (history, admitting diagnosis), Assessment (current vital signs, findings), Recommendation (interventions needed, next steps).

Q: Therapeutic communication: offering general leads
A: 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.

Q: Therapeutic communication: clarifying technique purpose
A: 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?'

Q: Tasks appropriate for unlicensed assistive personnel (UAP)
A: Stable patients with routine tasks: vital signs, hygiene, toileting, feeding (non-aspiration risk), ambulation, intake/output measurement, and documentation of completed tasks.

Q: Tasks that CANNOT be delegated to UAP
A: Nursing assessment, evaluation, patient teaching, medication administration, IV therapy, care planning, sterile procedures, and initial assessment of unstable patients remain RN responsibilities.

Q: Priority setting using ABC vs. Maslow conflict example
A: 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.

Q: Normal adult oral temperature range in Fahrenheit?
A: 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.

Q: Pulse pressure calculation and clinical significance
A: Pulse pressure = systolic BP minus diastolic BP. Normal is 30–50 mmHg. Widened (>60) suggests aortic regurgitation, atherosclerosis, or increased intracranial pressure; narrowed (

Q: Normal pediatric (1–10 year) heart rate range?
A: 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.

Q: Pain rating scales for cognitively impaired adults?
A: 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.

Q: PASS technique for fire extinguisher operation
A: 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.

Q: What does an SDS (Safety Data Sheet) provide?
A: 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.

Q: Enteric (contact) precaution indications
A: Enteric precautions are used for infections transmitted by fecal–oral route or contact with contaminated equipment: C. difficile, norovirus, rotavirus, and Vancomycin-resistant Enterococcus (VRE). Use soap and water for hand hygiene (alcohol does not kill C. difficile spores).

Q: Eye and face protection PPE indications
A: 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.

Q: IM injection site: ventrogluteal advantages
A: 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.

Q: Normal serum magnesium range and clinical use
A: 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.

Q: Signs of hypocalcemia
A: Hypocalcemia signs: numbness/tingling (circumoral and fingers), muscle cramps, Trousseau sign (carpal spasm with BP cuff inflation), Chvostek sign (facial twitch with tap on facial nerve), seizures, prolonged QT interval, and tetany. Causes include parathyroidectomy, vitamin D deficiency, and pancreatitis.

Q: Signs of hypercalcemia
A: 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.

Q: IV insulin drip titration in DKA
A: In DKA, regular insulin IV drip is titrated to reduce blood glucose by 50–75 mg/dL/hour. Once glucose reaches ~200 mg/dL, add D5W to IV fluids and continue insulin to correct acidosis. Monitor potassium—insulin drives K+ intracellularly; replace K+ when serum K+

Q: Signs of anaphylaxis requiring immediate intervention
A: Anaphylaxis signs: sudden urticaria/angioedema, wheezing/laryngeal edema, hypotension, tachycardia, and GI symptoms (cramping, vomiting). Treatment priority: administer IM epinephrine (0.3–0.5 mg adult) immediately, then oxygen, IV fluids, antihistamines, and corticosteroids.

Q: Position for patient after lumbar puncture
A: After lumbar puncture, position the patient flat supine (or as ordered) for 1–6 hours to prevent post-lumbar-puncture headache. Encourage increased oral fluid intake to promote CSF fluid replacement. Monitor for headache, CSF leak, and bleeding at puncture site.

Q: Deep vein thrombosis (DVT) clinical findings
A: 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.

Q: Five rights of delegation (delegation principles)
A: 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.

Q: Maslow priority example in nursing care
A: 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.

Q: ABC priority example: which patient to see first?
A: 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.

Q: Restatement vs. reflection in therapeutic communication
A: Restatement repeats the patient's main idea back to clarify meaning ('It sounds like you feel...'). Reflection focuses on feelings rather than content, paraphrasing emotions. Restatement clarifies content; reflection validates emotions. Both encourage continued sharing without judgment.

Q: Therapeutic communication: offering self vs. silence
A: 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').

Q: Normal adult MAP (mean arterial pressure) value and calculation?
A: Normal MAP is 70-100 mmHg. Calculation: MAP = (SBP + 2×DBP) ÷ 3. MAP reflects perfusion pressure to organs; values

Q: Temperature range for elderly adults and why it differs?
A: Elderly baseline temperature averages 95-97°F (35-36.1°C). Blunted thermoregulation, decreased shivering, and lower metabolic rate delay fever recognition; infection may present with confusion instead of fever.

Q: What is the difference between apical and radial pulse?
A: Apical pulse is auscultated at the 5th intercostal space, midclavicular line using a stethoscope. Radial pulse is palpated at the wrist. Apical is most accurate, especially for irregular rhythms and in infants.

Q: Why measure respiratory rate first without patient awareness?
A: 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.

Q: Correct cuff size for accurate blood pressure?
A: Bladder width should be 40% of arm circumference; length 80% of arm circumference. Too small falsely elevates readings; too large falsely lowers them. Use leg or thigh cuff when arm is too large.

Q: Why should BP not be taken on an arm with an IV?
A: 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.

Q: Korotkoff sounds: phases and which indicate diastolic?
A: 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.

Q: Braden Scale purpose and six subscales?
A: Braden Scale predicts pressure injury risk. Six subscales: sensory perception, moisture, activity, mobility, nutrition, friction/shear. Each scored 1-4 except friction/shear (1-3); total ≤18 indicates risk.

Q: Components of the Morse Fall Scale?
A: 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.

Q: Five rights of medication administration beyond the basic six?
A: 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).

Q: Why dilute and rotate sites with potassium chloride IV?
A: KCl must be diluted (typically 20-40 mEq/100 mL) and infused via a pump to prevent lethal hyperkalemia, cardiac arrhythmias, and phlebitis. Rotate peripheral sites; central lines preferred for concentrations >10 mEq/100 mL.

Q: Peak and trough timing for antibiotic levels?
A: Trough: drawn 30 minutes before next dose, measuring lowest drug level. Peak: drawn 30-60 minutes after IV infusion completion, measuring highest level. Ensures therapeutic range and prevents toxicity.

Q: First nursing action for suspected transfusion reaction?
A: 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.

Q: Signs of transfusion reaction to monitor for?
A: Fever, chills, urticaria, hypotension, dyspnea, chest pain, flank pain, hemoglobinuria. Severe reactions include anaphylaxis and TRALI (acute respiratory distress) occurring within 6 hours of transfusion.

Q: IV push medication dilution and time standard?
A: 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.

Q: Safe IV push of heparin protocol?
A: 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.

Q: Loop diuretic (furosemide) administration timing?
A: 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.

Q: Safe insulin storage and in-use rules?
A: 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.

Q: Mixing insulins: which drawn first?
A: Draw clear (regular) insulin first, then cloudy (NPH). Inject air into NPH vial first without drawing, then air into regular vial. This prevents contamination of regular insulin with NPH.

Q: Signs of insulin shock vs. diabetic ketoacidosis?
A: Insulin shock: hypoglycemia—tachycardia, sweating, tremor, confusion, seizures, low glucose (250.

Q: SIADH vs. diabetes insipidus sodium and urine findings?
A: SIADH: hyponatremia (145), dilute urine (low specific gravity), massive polyuria, and severe dehydration.

Q: First-line treatment for hypernatremia?
A: Treat underlying cause and replace water gradually. Use hypotonic IV fluids (D5W or 0.45% NS) slowly to avoid cerebral edema. Sodium should not decrease faster than 0.5 mEq/L per hour.

Q: ECG changes indicating hypokalemia?
A: Hypokalemia shows flattened or inverted T waves, prominent U waves, ST depression, and prolonged QT interval. Severe hypokalemia (

Q: Calcium gluconate administration in hyperkalemia: why?
A: 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).

Q: Chvostek's and Trousseau's signs indicate what imbalance?
A: Both indicate hypocalcemia. Chvostek's: facial muscle twitch when tapping facial nerve. Trousseau's: carpal spasm when BP cuff inflated above systolic for 3 minutes. Confirmed by ionized calcium

Q: First signs of magnesium toxicity?
A: 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.

Q: Anion gap calculation and metabolic acidosis?
A: 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.

Q: Therapeutic communication: open-ended question example?
A: Open-ended: 'Tell me how you're feeling about your diagnosis' vs. closed 'Are you feeling okay?'. Open questions encourage elaboration, reveal concerns, and demonstrate active listening and therapeutic engagement.

Q: Therapeutic communication: clarifying technique purpose?
A: 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.

Q: Therapeutic communication response to patient crying silently?
A: Use silence with presence, offer tissue, maintain eye contact, and quietly acknowledge: 'I can see this is very difficult for you.' Avoid premature reassurance or forcing speech; silence demonstrates acceptance.

Q: Cultural competency: LEARN model steps?
A: L: Listen to patient perspective. E: Explain your perception. A: Acknowledge similarities/differences. R: Recommend treatment. N: Negotiate plan that respects patient's cultural beliefs and values.

Q: Maslow's hierarchy: which level first for nursing prioritization?
A: 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.

Q: SBAR: example of effective Situation statement?
A: '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.'

Q: Delegation: which tasks cannot be delegated to UAP?
A: RN cannot delegate clinical judgment, assessment, teaching, evaluation, or nursing diagnosis. UAPs may perform ADLs, vital signs on stable patients, toileting, ambulation, and feeding without swallowing precautions.

Q: Stable vs. unstable patient criteria for delegation?
A: 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.

Q: LPN/LVN scope: which medication can they administer?
A: 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.

Q: Two-challenge rule for patient safety advocacy?
A: 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.

Q: Never events: examples nursing should prevent?
A: Never events include wrong-site surgery, retained surgical items, patient suicide in supervised care, falls with serious injury, and air embolism. Each requires root cause analysis and facility reporting.

Q: Delegation supervision requirements for RN?
A: RN must provide clear instructions, verify competency, supervise delegated tasks, evaluate outcomes, and maintain accountability. Documentation of delegation, supervision, and patient response is required.

Q: Pulse pressure calculation and clinical significance?
A: Pulse pressure = systolic minus diastolic. Normal is 30–50 mmHg. Widened (>60) suggests aortic regurgitation, anemia, or increased ICP; narrowed (

Q: Normal pediatric heart rate range (1–10 years)?
A: Approximately 70–130 beats per minute, varying with age. Younger children have faster rates; rates gradually decline toward adult norms (60–100) by adolescence.

Q: Biot respirations: description and significance?
A: Biot breathing shows irregular respirations with unpredictable deep and shallow breaths and apnea periods. Associated with increased intracranial pressure, brainstem injury, or severe CNS dysfunction.

Q: Kussmaul respirations: description and significance?
A: Kussmaul breathing is deep, rapid, and labored respirations (>20/min) without pauses. Classic compensatory response to metabolic acidosis, especially diabetic ketoacidosis (DKA) and renal failure.

Q: Cheyne-Stokes respirations: pattern and cause?
A: 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.

Q: Best site for pulse oximeter probe placement?
A: 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.

Q: Components of a comprehensive health history (4 sections)?
A: 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.

Q: Inspection vs. palpation order in physical assessment?
A: Inspect first, then palpate. Palpating before inspection can alter the area's appearance and miss subtle findings. Auscultation precedes percussion and palpation when assessing the abdomen.

Q: RACE protocol for fire response?
A: R = Rescue/remove patients from danger. A = Activate alarm and call code. C = Contain/close doors and windows. E = Extinguish if safe, or Evacuate horizontally if smoke is present.

Q: PASS technique for fire extinguisher operation?
A: 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.

Q: What does an MSDS (SDS) sheet provide?
A: Safety Data Sheets provide chemical hazard information: identification, physical data, fire/explosion risks, reactivity, health hazards, protective equipment, spill procedures, and first-aid measures.

Q: Proper needle recapping technique (if required)?
A: Use the one-handed scoop method: place the cap on a flat surface, slide the needle into the cap with one hand, then lift the cap with the other hand. Never use two hands to recap.

Q: Sharps container fill-level safety rule?
A: 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.

Q: Droplet precaution PPE requirements?
A: Surgical mask within 3 feet of patient (some facilities require for room entry). Private room preferred or cohort with same infection. Door may remain closed; no special ventilation required.

Q: Diseases requiring airborne precautions?
A: Measles (rubeola), varicella (chickenpox), disseminated varicella zoster, and pulmonary/laryngeal tuberculosis. Requires N95 respirator and negative-pressure airborne infection isolation room (AIIR).

Q: Neutropenic precautions for immunocompromised patients?
A: 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.

Q: Enteric (contact) precaution indications?
A: For infections spread by fecal-oral route or contact with contaminated body fluids: Clostridioides difficile, rotavirus, norovirus, hepatitis A, shigellosis. Requires gown and gloves; soap and water preferred over alcohol for C. diff.

Q: Eye/face protection PPE indications?
A: 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).

Q: Order of donning PPE?
A: 1) Gown first (tie at neck and waist). 2) Mask or respirator (fit-check N95). 3) Goggles or face shield. 4) Gloves last, covering gown cuffs. Always perform hand hygiene before and after.

Q: Three checks of medication administration?
A: 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.

Q: PRN medication documentation requirements?
A: Document the medication, dose, time given, patient response including pain rating before/after, reason for administration, and evaluation of effectiveness. PRN orders also require documented indication for use.

Q: Ventrogluteal IM injection site advantages?
A: 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.

Q: Insulin onset/peak/duration for NPH (intermediate-acting)?
A: 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.

Q: Insulin onset/peak for long-acting glargine (Lantus)?
A: 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.

Q: Routes of medication administration abbreviations?
A: PO (by mouth), IV (intravenous), IM (intramuscular), SC/SQ (subcutaneous), ID (intradermal), SL (sublingual), PR (rectal), PV (vaginal), IN (intranasal), IT (intrathecal), Neb (nebulizer), GT (gastrostomy tube).

Q: Signs and symptoms of hyperkalemia?
A: 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.

Q: First-line treatment for severe hyperkalemia?
A: 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.

Q: Signs of fluid volume deficit (hypovolemia)?
A: Restlessness, thirst, dry mucous membranes, decreased skin turgor (tenting), tachycardia, hypotension, weak/thready pulse, decreased urine output (

Q: Signs of hypokalemia?
A: 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.

Q: IV infiltration signs and nursing action?
A: 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.

Q: Extravasation of vesicant chemotherapy: nursing action?
A: 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.

Q: Therapeutic communication technique: silence?
A: 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.

Q: Therapeutic communication technique: clarification?
A: 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.

Q: SBAR communication format components?
A: 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).

Q: Maslow's hierarchy applied to nursing prioritization?
A: 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.

Q: Five Rights of Delegation (NCSBN)?
A: 1) Right task, 2) Right circumstance, 3) Right person (staff competency), 4) Right direction/communication, 5) Right supervision/evaluation. Nurse retains accountability for the delegated task and patient outcome.

Q: Tasks appropriate for nursing assistive personnel (NAP)?
A: 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.

Q: Tasks NOT appropriate for LPN/LVN delegation?
A: 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.

Q: What is the normal adult oral temperature range in °C?
A: 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.

Q: Average normal oral temperature for adults?
A: 37.0 °C (98.6 °F). This is the typical baseline; individual baseline may vary ±0.5 °C, so trends are more clinically significant than single readings.

Q: Febrile temperature threshold (oral) in adults?
A: ≥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.

Q: Tympanic vs. oral temperature comparison?
A: 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.

Q: Rectal temperature vs. oral accuracy?
A: Rectal temperature is typically 0.5–1.0 °C (1.0–2.0 °F) higher than oral and considered closest to core body temperature. Avoid in neutropenic, rectal surgery, or cardiac patients.

Q: Axillary temperature reliability?
A: Axillary readings average 0.5–1.0 °C lower than oral. Considered least reliable; reserved for oral-contraindicated situations. Document site clearly.

Q: Temporal artery thermometer advantage?
A: Temporal scanning is rapid, noninvasive, and well-tolerated. Studies show agreement with oral readings within ±0.2 °C; avoid scanning over hair-covered or diaphoretic areas.

Q: What is the normal adult respiratory rate?
A: 12–20 breaths per minute. Bradypnea 20 require further assessment; always count a full 60 seconds for accuracy.

Q: Why count respirations without patient awareness?
A: Awareness alters breathing pattern. Count immediately after palpating pulse while still holding the wrist, appearing to continue pulse assessment.

Q: Normal adult heart rate range?
A: 60–100 beats per minute. 100 = tachycardia. Assess rhythm and perfusion, not just rate.

Q: Hypertensive crisis BP threshold?
A: >180/120 mmHg requires urgent evaluation. Hypertensive emergency includes end-organ damage; urgency does not. Repeat in both arms after 5 minutes rest.

Q: Pulse pressure calculation and significance?
A: Systolic minus diastolic. Normal 30–50 mmHg. Wide (>60) suggests aortic regurgitation, aneurysm, or hyperthyroidism. Narrow (

Q: When is apical pulse the preferred site?
A: Infants, irregular rhythms (e.g., atrial fibrillation), pre/post cardiac medication administration, and when radial pulse is inaccessible or inaccurate.

Q: Apical pulse measurement procedure?
A: Use stethoscope at 5th intercostal space, midclavicular line (PMI). Count for 60 seconds (especially if irregular). Document rate, rhythm, and any murmurs.

Q: Biot respirations description and significance?
A: Groups of quick, shallow gasps followed by irregular apnea. Associated with increased intracranial pressure, brainstem injury, or impending respiratory arrest.

Q: Kussmaul respirations description and significance?
A: Deep, rapid, labored breathing (often >30/min). Compensation for metabolic acidosis, classically DKA; also renal failure, salicylate toxicity.

Q: Cheyne-Stokes respirations pattern and cause?
A: Crescendo-decrescendo pattern alternating with apnea. Causes: heart failure, stroke, increased ICP, opioid overdose, brain injury; often poor prognosis.

Q: Pulse oximetry limitation in anemic patients?
A: SpO2 measures saturation %, not oxygen content. Severe anemia with normal SpO2 may still cause tissue hypoxia due to low hemoglobin-bound oxygen delivery.

Q: Pulse oximetry in carbon monoxide poisoning?
A: Falsely elevated/high SpO2 because COHb absorbs light similarly to oxyhemoglobin. Use co-oximetry (SaO2 with COHb level) for accurate assessment.

Q: Numeric pain scale (0–10) interpretation?
A: 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.

Q: Components of a comprehensive health history?
A: Biographic data, reason for seeking care (chief complaint), history of present illness (OLD HART/CHARTS), past medical/surgical/family/social history, review of systems.

Q: Inspection vs. palpation order?
A: Inspect first (visual before touching), then palpate (light to deep), then percuss, then auscultate. Exception: abdomen—auscultate before percussing/palpating to avoid altering bowel sounds.

Q: Subjective vs. objective data example?
A: Subjective: 'I feel short of breath' (patient report). Objective: respiratory rate 28, SpO2 88%, wheezing on auscultation. Both are essential for nursing diagnosis.

Q: Components of a focused assessment?
A: 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.

Q: PQRST pain assessment mnemonic meaning?
A: P=Provoke/Palliate, Q=Quality, R=Radiation, S=Severity (0–10), T=Timing (onset, duration, frequency). Comprehensive pain characterization guiding differential diagnosis.

Q: Primary nursing survey (ABCDE) components?
A: Airway (with C-spine), Breathing, Circulation, Disability (neuro status), Exposure (full view while preventing hypothermia). Rapid systematic trauma/initial assessment.

Q: Secondary survey purpose?
A: Head-to-toe assessment, full history (AMPLE: Allergies, Medications, Past medical, Last meal, Events), vital signs, diagnostics after primary survey is stable.

Q: AMPLE history mnemonic meaning?
A: Allergies, Medications (prescription/OTC/herbal), Past medical/surgical history, Last meal (NPO status), Events leading to injury/illness. Standard trauma history.

Q: Glasgow Coma Scale components?
A: Eye opening (1–4), Verbal response (1–5), Motor response (1–6). Total 3–15; ≤8 indicates severe brain injury and intubation consideration. Document individual scores.

Q: Fall risk assessment tool example?
A: Morse Fall Scale assesses history of falling, secondary diagnosis, ambulatory aid, IV/Heparin lock, gait, mental status. Score ≥45 = high risk; implement tailored interventions.

Q: Universal fall precautions interventions?
A: 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.

Q: Restraint use legal requirements?
A: MD order required; least restrictive type; renewed every 24 hours (varies by state); face-to-face evaluation within 1 hour; PRN orders prohibited; document trials of less restrictive alternatives.

Q: Hand hygiene indications (WHO 5 Moments)?
A: 1) Before patient contact, 2) Before aseptic task, 3) After body fluid exposure risk, 4) After patient contact, 5) After contact with patient surroundings. Alcohol rub 20–30 seconds minimum.

Q: Standard vs. contact precautions?
A: Standard: all patients, all body fluids except sweat. Contact: gown + gloves for MRSA, C. diff, wound/skin infections; private room; dedicated equipment.

Q: Droplet precaution distance and PPE?
A: 3 feet (1 meter) or private room; surgical mask within 6 feet, patient wears mask during transport. Examples: influenza, pertussis, meningococcal disease, mumps.

Q: Enteric (contact) precautions indications?
A: C. difficile, norovirus, rotavirus, Shigella, hepatitis A (diapered patients). Soap and water handwashing required—alcohol does not kill C. diff spores.