NCLEX-RN (Registered Nurse) Flashcards
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Normal adult vital sign ranges (temp, HR, RR, BP)?
Temp ~36.5–37.5°C (97.7–99.5°F); HR 60–100 bpm; RR 12–20/min; BP <120/80 mmHg (normal).
What are the early vs. late signs of hypoxia?
Early: restlessness, anxiety, tachycardia, tachypnea. Late: cyanosis, bradycardia, confusion/decreased LOC. Cyanosis is a late sign.
What is the correct order of the nursing process (ADPIE)?
Assessment → Diagnosis → Planning → Implementation → Evaluation. Assessment (data collection) always comes first.
In Maslow's hierarchy, which needs take priority when setting nursing care priorities?
Physiological needs first (airway, breathing, circulation), then safety, then love/belonging, self-esteem, and self-actualization.
What does the ABC priority framework stand for?
Airway, Breathing, Circulation — the order for prioritizing patient interventions in an emergency.
What are the standard/universal precautions applied to ALL patients?
Treat all blood and body fluids as infectious: hand hygiene, gloves, gowns, masks/eye protection as indicated, and safe sharps handling.
Which patients require airborne precautions (and what PPE)?
TB, measles (rubeola), varicella. Use a negative-pressure room and an N95 respirator.
What is the antidote for opioid overdose, and for benzodiazepine overdose?
Opioid overdose: naloxone (Narcan). Benzodiazepine overdose: flumazenil.
How do you position a patient after a lumbar puncture and why?
Keep flat (supine) for several hours and encourage fluids to reduce the risk of a post-procedure spinal headache from CSF leakage.
What are the 5 Rights of medication administration?
Right patient, Right drug, Right dose, Right route, Right time (often expanded with right documentation and right reason).
Which food/drug is the priority to teach a patient starting an MAOI?
Avoid tyramine-rich foods (aged cheese, cured meats, red wine, fermented foods) to prevent hypertensive crisis.
In delegation, which tasks can be assigned to a UAP (unlicensed assistive personnel)?
Stable, predictable tasks: bathing, feeding, vital signs, ambulation, and I&O. Never delegate assessment, teaching, evaluation, or care of unstable patients.