Fluid & Electrolytes
The single most accurate daily clinical indicator of a client's fluid volume status.
What is daily weight (measured at the same time, on the same scale, with the same clothing; 1 kg = 1 L of fluid)
Non-negotiable intraoperative safety protocol initiated by the circulating nurse immediately before skin incision
What is the Surgical Time Out
The "Rule of 15" for acute hypoglycemia specifies giving 15 grams of fast-acting carbs and waiting this long to recheck blood glucose
What is 15 minutes
Essential nursing action that MUST be completed prior to administering the first dose of IV broad-spectrum antibiotics for pneumonia
What is drawing blood cultures (x2 separate sites)
When should Sequential Compression Devices (SCDs) be applied to a surgical patient, and when can they be safely discontinued?
Applied before surgery in pre-op and kept on postoperatively until the client is fully ambulatory
High-alert safety protocol that dictates potassium chloride (KCl) must NEVER be administered using this method.
What is IV Push (it must always be diluted and administered via infusion pump at a max rate of 10 mEq/hr)
Preoperative medication ingestion that must be reported to the surgeon immediately due to increased surgical bleeding risk
What is aspirin (or fish oil)
Crucial medication safety protocol for a Type 2 diabetic scheduled for a CT scan with IV contrast
What is holding Metformin before contrast administration
Required infection control isolation protocol and room setup for a client admitted with active Tuberculosis
What are Airborne Precautions in a negative-pressure single room (with N95 respirators for staff)
A post-op abdominal surgery client refuses to use their incentive spirometer because coughing causes severe incisional pain. What is the nurse's immediate priority action?
Administer prescribed pain medication first, wait for it to take effect, and re-teach splinting with a pillow
Laboratory findings showing elevated BUN, elevated serum sodium, and elevated hematocrit indicate this fluid imbalance state
What is hypovolemia
The primary legal and professional role of the nurse regarding a surgical informed consent form
What is witnessing the client's signature and verifying understanding (not obtaining informed consent)
In Diabetic Ketoacidosis (DKA), this electrolyte level must be checked and corrected BEFORE initiating IV regular insulin
What is Potassium ($K^+$)
Mandatory position elevation for head of bed to prevent aspiration pneumonia in tube-fed clients
What is elevating the head of bed at least 30 degrees (Semi-Fowler's)
Following a transsphenoidal hypophysectomy, a client has a urine output of 450 mL/hr, urine specific gravity of 1.001, and serum sodium of 152 mEq/L. What complication is developing, and what medication treats it?
Diabetes Insipidus (DI); treated with Desmopressin (DDAVP)
The classic ECG change seen in severe hyperkalemia that warns of imminent cardiac arrest
What are tall peaked T waves
Immediate priority nursing intervention for a post-op client refusing incentive spirometry due to severe incisional pain
What is administering prescribed pain medication first (and then re-teaching splinting with a pillow)
Which lab value tests for general diabetes management over 2-3 months?
hemoglobin (A1C)
Recommended post-procedure positioning following a thoracentesis to promote expansion and prevent complications
What is positioning the client on the unaffected side for 1 hour
You are the intraop RN and suddenly notice your patient's HR climb into the 120's, their temp dramatically rise to 104f, and their muscles are slightly rigid, what is going on and what order to you anticipate administering?
malignant hyperthermia and IV dantrolene
The IV medication given during severe hyperkalemia to protect the cardiac cell membrane before shifting potassium into cells
What is IV Calcium Gluconate
Key physical findings that signal Malignant Hyperthermia during surgery.
Tachycardia, rapid temperature elevation, & muscle rigidity
Emergency airway equipment that must be kept at the bedside immediately following a subtotal thyroidectomy
What is a tracheostomy tray
Breathing technique taught to COPD patients where exhalation is twice as long as inhalation to prevent air trapping
What is pursed-lip breathing
Tapping the facial nerve anterior to the ear causes a twitch of the facial muscles in this assessment sign, which indicates acute hypocalcemia.
What is a positive Chvostek's sign?