Vital Signs
This is the normal respiratory rate range for an adult patient.
What is 12-20 breaths per minute
This is the first priority assessment when receiving a patient from the operating room
What is Airway, Breathing, Circulation (ABCs)
This stage of pressure injury involves intact skin with non-blanchable redness, usually over a bony prominence
What is Stage I pressure injury
This electrolyte imbalance is characterized by muscle cramps, cardiac arrhythmias, and tall, peaked T waves on ECG.
What is hyperkalemia?
Before administering any medication, the nurse verifies these '5 Rights' to ensure patient safety.
What are the right patient, right drug, right dose, right route, and right time?
When assessing blood pressure, the first sound you hear through the stethoscope represents this pressure reading
What is systolic blood pressure
The nurse instructs the post-operative patient to use this device every 1-2 hours while awake to expand the lungs and prevent atelectasis
What is incentive spirometer
This type of wound drainage is thick, yellow, green, or brown and indicates infection.
What is purulent drainage?
Serous - clear, watery (normal)
Sanguineous - bloody, red (normal early post-op)
Serosanguineous - pink, mix of serous and blood (common during healing)
Purulent - thick, yellow/green/brown (indicates infection)
The nurse assesses poor skin turgor, dry mucous membranes, and concentrated urine in a patient with this fluid imbalance
What is dehydration (or fluid volume deficit/hypovolemia)?
The nurse holds the morning dose of metoprolol when the patient's heart rate is below this number.
What is 60 bpm?
A patient with a temperature of 96.5°F is experiencing this condition, which can occur with sepsis or hypothyroidism
What is Hypothermia
his post-operative complication is characterized by sudden chest pain, dyspnea, and anxiety, and may occur when a clot travels to the lungs
What is Pulmonary Embolism
The nurse repositions a bedridden patient at least every 2 hours to prevent this type of injury caused by prolonged pressure over bony prominences.
What is a pressure injury
This electrolyte is essential for muscle contraction and nerve function, and its deficiency can cause Trousseau's sign and Chvostek's sign
What is Calcium (hypocalcemia)?
This opioid reversal agent is administered for respiratory depression caused by morphine or fentanyl overdose.
What is Narcan?
Before taking an oral temperature, the nurse should wait this many minutes if the patient has consumed hot or cold beverages
What is 15-30 minutes
When assessing a surgical incision, the nurse notes redness, warmth, purulent drainage, and the patient has a fever - these are signs of this complication
What is Surgical Site Infection (SSI)
This type of wound drainage is clear, watery, and considered normal in the early stages of wound healing
What is Serous Drainage
Serous - clear, watery (normal)
Sanguineous - bloody, red (normal early post-op)
Serosanguineous - pink, mix of serous and blood (common during healing)
Purulent - thick, yellow/green/brown (indicates infection)
A patient with SIADH (Syndrome of Inappropriate Antidiuretic Hormone) would most likely present with this sodium imbalance due to water retention.
HINT: Hyponatremia or Hypernatremia?
What is hyponatremia?
When administering IV vancomycin, the nurse infuses it slowly over at least 60 minutes to prevent this flushing reaction of the face, neck, and trunk.
What is Red Man Syndrome (or vancomycin flushing syndrome)
This term describes an abnormally high respiratory rate above 20 breaths per minute and is often seen in patients with fever, pain, or respiratory distress
What is tachypnea
The nurse monitors for this serious complication when a post-operative patient's wound edges separate, potentially exposing underlying tissue or organs.
What is dehiscence (or evisceration if organs are protruding)
The nurse assesses the tissue in the wound bed and documents this type of dead, black, leathery tissue that must be debrided for healing to occur.
What is Eschar
The nurse knows that this IV fluid is isotonic and commonly used for fluid resuscitation, containing 0.9% sodium chloride.
What is Normal Saline?
A patient on warfarin has an elevated INR of 5.2. The nurse anticipates administering this vitamin as an antidote
What is Vitamin K?