Management of Care
This is the "Right" of delegation that ensures the task is within the UAP's job description and legal scope.
What is Right Task?
This is the most common side effect of ACE inhibitors (like Lisinopril) that may lead to the medication being discontinued.
What is a dry, persistent cough?
This is the first action a nurse should take when a client's chest tube becomes disconnected from the drainage system.
What is placing the end of the tube in sterile water? (To create a water seal).
This is the acronym used to remember the sequence of actions during a fire: Rescue, Alarm, Confine, Extinguish.
What is R.A.C.E.?
This defense mechanism involves a client "forgetting" a traumatic event or pushing it into the unconscious mind.
What is Repression?
This legal document allows a client to specify medical treatments they desire (or wish to refuse) if they become incapacitated.
What is a Living Will?
When administering Digoxin, the nurse must hold the medication if the apical pulse is less than this many beats per minute in an adult.
What is 60 bpm?
After a liver biopsy, the patient should be positioned on this side to provide pressure to the site and prevent bleeding.
What is the Right Side?
When removing Personal Protective Equipment (PPE), this item is typically removed first to prevent contamination.
What are gloves?
This is the priority nursing intervention for a client experiencing a Panic Attack.
What is staying with the client (and using short, simple sentences)?
When an RN is assigned to a group of patients, this client should be assessed first: A patient 1-day post-op or a patient reporting sudden chest pain?
What is the patient reporting sudden chest pain? (ABC priority).
This medication is the "antidote" used to reverse the effects of an opioid overdose.
What is Naloxone (Narcan)?
This electrolyte imbalance is a major risk for a patient taking Loop Diuretics like Furosemide.
What is Hypokalemia?
This type of precaution is required for a patient with Disseminated Herpes Zoster or Vancomycin-resistant Enterococcus (VRE).
What are Contact Precautions?
In the "Stages of Grief" by Kübler-Ross, this stage often involves the patient trying to "make a deal" with a higher power.
What is Bargaining?
This is the ethical principle of "doing good" and acting in the best interest of the patient.
What is Beneficence?
Clients taking Warfarin must maintain a consistent intake of this vitamin to avoid fluctuating INR levels.
What is Vitamin K?
A glycosylated hemoglobin (HbA1c) level above this percentage typically indicates poorly controlled Diabetes Mellitus.
What is 7%? (Target is usually < 7%).
To maintain a sterile field, the nurse should drop sterile items onto the field from a height of at least this many inches.
What is 6 inches?
A patient who believes the TV is sending them special secret messages is experiencing this type of thought process.
What are Delusions of Reference?
An RN can delegate this specific part of the nursing process to an LPN/LVN, but never to a UAP/CNA.
What is Data Collection (or specific Task-oriented implementation)?
This life-threatening reaction to antipsychotic medications involves high fever, muscle rigidity, and autonomic instability.
What is Neuroleptic Malignant Syndrome (NMS)?
In a patient with a head injury, this is the earliest and most sensitive indicator of increased intracranial pressure.
What is a change in Level of Consciousness (LOC)?
This is the only type of jewelry allowed to be worn by a nurse in a sterile surgical environment.
What is none? (or a plain wedding band, depending on facility policy, but "none" is the safest NCLEX answer).
This is the primary therapeutic communication technique used when a nurse says, "It sounds like you are feeling overwhelmed today."
What is Reflection (or Validating)?