Electrolytes: Sodium	Usual adult range: 135–145 mEq/L; Low: key signs: Confusion, headache, seizures; correct slowly; High: key signs: Thirst, agitation, dry mucosa; seizures if severe
Electrolytes: Potassium	Usual adult range: 3.5–5.0 mEq/L; Low: key signs: Muscle weakness, cramps, constipation, flat T waves, U waves; High: key signs: Muscle weakness, peaked T waves, dysrhythmias
Electrolytes: Calcium (total)	Usual adult range: About 8.5–10.5 mg/dL; Low: key signs: Tetany, Trousseau and Chvostek signs, prolonged QT; High: key signs: Weakness, constipation, kidney stones, confusion
Electrolytes: Magnesium	Usual adult range: About 1.5–2.5 mg/dL; Low: key signs: Tremor, hyperreflexia, torsades; makes hypokalemia hard to correct; High: key signs: Loss of deep tendon reflexes, respiratory depression, hypotension
Electrolytes: Phosphorus	Usual adult range: About 2.5–4.5 mg/dL; Low: key signs: Weakness (refeeding syndrome); High: key signs: Usually with kidney failure; itching, low calcium
Blood counts and coagulation: Test: WBC	Usual adult range: About 5,000–10,000/mm³; Nursing significance: High: infection, inflammation, steroids. Low: infection risk
Blood counts and coagulation: Absolute neutrophil count	Usual adult range: Below 500/mm³ = severe neutropenia; Nursing significance: Neutropenic precautions: hand hygiene, avoid sick contacts, report fever immediately
Blood counts and coagulation: Hemoglobin	Usual adult range: About 12–16 g/dL (F), 14–18 g/dL (M); Nursing significance: Low: bleeding, anemia; assess for fatigue, tachycardia, dyspnea
Blood counts and coagulation: Hematocrit	Usual adult range: About 37–47% (F), 42–52% (M); Nursing significance: Rises with dehydration; falls with bleeding or fluid overload
Blood counts and coagulation: Platelets	Usual adult range: 150,000–400,000/mm³; Nursing significance: Low: bleeding precautions; a fall of 50% on heparin suggests HIT
Blood counts and coagulation: PT/INR	Usual adult range: INR about 1.0 off warfarin; target usually 2–3; Nursing significance: Monitors warfarin; high INR → hold and notify
Blood counts and coagulation: aPTT	Usual adult range: About 30–40 seconds; Nursing significance: Monitors IV heparin (therapeutic about 1.5–2.5 × control)
Arterial blood gases: Respiratory acidosis	pH: ↓; Primary change: PaCO₂ ↑; Common causes: Hypoventilation: opioids, COPD, neuromuscular weakness
Arterial blood gases: Respiratory alkalosis	pH: ↑; Primary change: PaCO₂ ↓; Common causes: Hyperventilation: anxiety, pain, early PE, high altitude
Arterial blood gases: Metabolic acidosis	pH: ↓; Primary change: HCO₃⁻ ↓; Common causes: DKA, lactic acidosis, kidney failure, diarrhea
Arterial blood gases: Metabolic alkalosis	pH: ↑; Primary change: HCO₃⁻ ↑; Common causes: Vomiting, NG suction, diuretics, excess antacids
Therapeutic drug levels and other values: Fasting glucose	Usual adult value: 70–99 mg/dL; Nursing note: Below 70 = hypoglycemia; treat with the 15-15 rule
Therapeutic drug levels and other values: HbA1c	Usual adult value: Below 5.7%; 6.5% or higher = diabetes; Nursing note: Reflects about 3 months of glucose
Therapeutic drug levels and other values: Test: BUN	Usual adult value: About 10–20 mg/dL; Nursing note: Rises with dehydration, GI bleeding, kidney failure
Therapeutic drug levels and other values: Creatinine	Usual adult value: About 0.6–1.2 mg/dL; Nursing note: Best routine marker of kidney function; check before nephrotoxic drugs and contrast
Therapeutic drug levels and other values: Albumin	Usual adult value: About 3.5–5.0 g/dL; Nursing note: Low: malnutrition, liver disease, edema, poor wound healing
Therapeutic drug levels and other values: Test: BNP	Usual adult value: Below 100 pg/mL; Nursing note: Elevated in heart failure
Prenatal care: Due date (Naegele's rule)	Key facts: LMP + 7 days − 3 months + 1 year
Prenatal care: Fundal height	Key facts: At the umbilicus about 20 weeks; from 20–36 weeks, height in cm ≈ weeks of gestation
Prenatal care: GTPAL	Key facts: Gravida, Term births, Preterm births, Abortions/miscarriages, Living children
Prenatal care: Gestational diabetes screening	Key facts: Usually 24–28 weeks
Prenatal care: Rh immune globulin	Key facts: Rh-negative client: about 28 weeks, after bleeding or procedures, and within 72 hours of birth of an Rh-positive newborn
Prenatal care: Danger signs to teach	Key facts: Vaginal bleeding, fluid leaking, decreased fetal movement, severe headache, visual changes, epigastric pain, swelling of face or hands
Fetal heart rate monitoring: Baseline 110–160/min with moderate variability	Cause: Well-oxygenated fetus; Nursing action: Continue monitoring
Fetal heart rate monitoring: Accelerations	Cause: Fetal well-being; Nursing action: Reassuring
Fetal heart rate monitoring: Early decelerations (mirror contractions)	Cause: Head compression; Nursing action: No intervention needed
Fetal heart rate monitoring: Variable decelerations (abrupt, V or W shaped)	Cause: Cord compression; Nursing action: Reposition; check for cord prolapse; notify if persistent
Fetal heart rate monitoring: Late decelerations (begin after the contraction peak)	Cause: Uteroplacental insufficiency; Nursing action: Stop oxytocin, reposition (side-lying), IV fluid bolus, notify; oxygen per protocol
Fetal heart rate monitoring: Minimal or absent variability	Cause: Hypoxia, sleep, or drugs; Nursing action: Assess; notify
Preeclampsia and magnesium sulfate: Blood pressure	Threshold or sign: ≥ 160 systolic or ≥ 110 diastolic
Preeclampsia and magnesium sulfate: Neurologic	Threshold or sign: New headache, visual disturbances
Preeclampsia and magnesium sulfate: Liver	Threshold or sign: Right upper quadrant or epigastric pain, elevated transaminases
Preeclampsia and magnesium sulfate: Blood	Threshold or sign: Platelets below 100,000/mm³ (HELLP syndrome: hemolysis, elevated liver enzymes, low platelets)
Preeclampsia and magnesium sulfate: Kidney and lung	Threshold or sign: Rising creatinine, pulmonary edema
Postpartum and newborn care: Heart rate	0: Absent; 1: Below 100; 2: 100 or more
Postpartum and newborn care: Respiratory effort	0: Absent; 1: Slow, irregular; 2: Good cry
Postpartum and newborn care: Muscle tone	0: Limp; 1: Some flexion; 2: Active motion
Postpartum and newborn care: Reflex irritability	0: None; 1: Grimace; 2: Cry, cough, sneeze
Postpartum and newborn care: Color	0: Blue or pale; 1: Body pink, extremities blue; 2: Completely pink
Recognize cues: left vs right failure: Daily weight	What to look for: Gain of 2–3 lb in 24 h or 5 lb in a week; Why it matters: Fluid retention appears on the scale before edema is obvious
Recognize cues: left vs right failure: Lung sounds	What to look for: New or spreading crackles; Why it matters: Worsening pulmonary congestion
Recognize cues: left vs right failure: SpO₂ and respiratory rate	What to look for: Falling SpO₂, tachypnea; Why it matters: Impaired gas exchange
Recognize cues: left vs right failure: Edema	What to look for: Pitting in legs or sacrum (bedbound clients); Why it matters: Fluid overload
Recognize cues: left vs right failure: Intake and output	What to look for: Intake exceeding output; Why it matters: Retention or inadequate diuresis
Recognize cues: left vs right failure: Potassium	What to look for: Below the normal range (about 3.5–5.0 mEq/L); Why it matters: Diuretics waste K⁺; hypokalemia increases digoxin toxicity
Recognize cues: left vs right failure: Assessment: BNP	What to look for: Elevated; Why it matters: Supports heart failure; trends with treatment
Pharmacological therapies: Furosemide (loop diuretic)	Before giving: BP, potassium, I&O; Monitor and teach: Hypokalemia, dehydration, orthostatic hypotension; give in the morning; report muscle cramps or weakness
Pharmacological therapies: Spironolactone (K⁺-sparing)	Before giving: Potassium, renal function; Monitor and teach: Hyperkalemia; avoid salt substitutes containing potassium
Pharmacological therapies: Digoxin	Before giving: Apical pulse for 1 full minute; potassium; digoxin level if ordered; Monitor and teach: Toxicity: nausea, vomiting, anorexia, visual changes (yellow-green halos), bradycardia, dysrhythmias
Pharmacological therapies: ACE inhibitors (lisinopril)	Before giving: BP, potassium, creatinine; Monitor and teach: Dry cough, angioedema (emergency), hyperkalemia; rise slowly
Pharmacological therapies: Beta blockers (metoprolol, carvedilol)	Before giving: Heart rate and BP; Monitor and teach: Fatigue, bradycardia; do not stop abruptly
Client teaching and an NGN-style case: Weigh daily at the same time with the same scale and clothing	Rationale: Detects fluid retention early
Client teaching and an NGN-style case: Follow the prescribed sodium restriction; read labels	Rationale: Sodium causes fluid retention
Client teaching and an NGN-style case: Follow any prescribed fluid limit	Rationale: Prevents overload in advanced disease
Client teaching and an NGN-style case: Rise slowly; take medications as prescribed	Rationale: Diuretics and vasodilators cause orthostatic hypotension
Client teaching and an NGN-style case: Pace activities and rest	Rationale: Reduces cardiac workload
Rights of medication administration: U, IU	Use instead: Write "unit" or "international unit"; Why: "U" can be misread as 0 or 4
Rights of medication administration: Q.D., Q.O.D.	Use instead: Write "daily" or "every other day"; Why: Confused with each other
Rights of medication administration: Trailing zero (5.0 mg)	Use instead: 5 mg; Why: Misread as 50 mg
Rights of medication administration: Missing leading zero (.5 mg)	Use instead: 0.5 mg; Why: Misread as 5 mg
Rights of medication administration: MS, MSO₄, MgSO₄	Use instead: Morphine sulfate; magnesium sulfate; Why: Confused with each other
Dosage calculation: Tablets or liquid	Formula: Desired ÷ Have × Quantity; Example: Order 500 mg; have 250 mg per 5 mL → 500 ÷ 250 × 5 = 10 mL
Dosage calculation: Weight-based	Formula: mg/kg × weight (kg); Example: 2 mg/kg for 70 kg → 140 mg
Dosage calculation: IV pump rate (mL/h)	Formula: Total volume (mL) ÷ time (h); Example: 1,000 mL over 8 h → 125 mL/h
Dosage calculation: Gravity drip (gtt/min)	Formula: Volume (mL) × drop factor (gtt/mL) ÷ time (min); Example: 1,000 mL × 15 gtt/mL ÷ 480 min ≈ 31 gtt/min
Dosage calculation: Pounds to kilograms	Formula: lb ÷ 2.2; Example: 154 lb ÷ 2.2 = 70 kg
Routes and techniques: Oral	Key points: Do not crush enteric-coated or extended-release products; check swallowing
Routes and techniques: Enteral tube	Key points: Give each drug separately; flush with water before, between, and after per policy
Routes and techniques: Subcutaneous	Key points: 45–90° angle; insulin and heparin in the abdomen; rotate sites
Routes and techniques: Intramuscular	Key points: Ventrogluteal site preferred in adults; Z-track for irritating drugs
Routes and techniques: IV push	Key points: Verify compatibility, dilution, and rate; check patency; push over the time stated
Routes and techniques: Sublingual	Key points: Under the tongue until dissolved; no swallowing or drinking
Growth and development: Infant (0–1 yr)	Erikson stage: Trust vs mistrust; Nursing application: Consistent caregivers; meet needs promptly
Growth and development: Toddler (1–3 yr)	Erikson stage: Autonomy vs shame and doubt; Nursing application: Offer simple choices; expect negativism and separation anxiety
Growth and development: Preschool (3–6 yr)	Erikson stage: Initiative vs guilt; Nursing application: Use play and dolls to explain procedures; fears of body injury
Growth and development: School age (6–12 yr)	Erikson stage: Industry vs inferiority; Nursing application: Explain procedures; involve in care; keep up schoolwork
Growth and development: Adolescent (12–18 yr)	Erikson stage: Identity vs role confusion; Nursing application: Privacy, peers, body image; interview without parents when appropriate
Dehydration and fluids: Daily weight (same scale, same time)	Why it matters: Most accurate measure of fluid change
Dehydration and fluids: Wet diapers or urine output	Why it matters: About 1 mL/kg/h or more is commonly expected in infants and young children
Dehydration and fluids: Fontanel, mucosa, tears	Why it matters: Early signs
Dehydration and fluids: Heart rate and capillary refill	Why it matters: Tachycardia comes before hypotension
Medications, Kawasaki disease, and safety: Kawasaki disease	Key nursing points: Fever ≥ 5 days, conjunctivitis, red cracked lips, strawberry tongue, rash, swollen hands and feet; risk of coronary artery aneurysm; IVIG and aspirin as ordered
Medications, Kawasaki disease, and safety: After IVIG	Key nursing points: Live vaccines (such as MMR and varicella) are usually deferred for about 11 months
Medications, Kawasaki disease, and safety: Aspirin	Key nursing points: Avoid for viral illness in children (Reye syndrome), except when prescribed, as in Kawasaki disease
Medications, Kawasaki disease, and safety: Safe sleep	Key nursing points: Back to sleep, firm flat surface, no pillows or bumpers, room-sharing without bed-sharing
Medications, Kawasaki disease, and safety: Car seats	Key nursing points: Rear-facing as long as possible, until the seat's height or weight limit
Medications, Kawasaki disease, and safety: Poisoning	Key nursing points: Lock up medicines and chemicals; Poison Control 1-800-222-1222 (U.S.)
Fall prevention: Bed in lowest position, wheels locked	Why: Reduces injury if the client gets up
Fall prevention: Call light, phone, water within reach	Why: Reduces unassisted reaching and walking
Fall prevention: Scheduled toileting and regular rounding	Why: Urgency is a common reason for falls
Fall prevention: Nonskid footwear, night light, clear path	Why: Safer walking
Fall prevention: Bed or chair alarms per policy	Why: Alerts staff early
Restraints: Order	Detail: Time-limited order from an authorized provider; never as needed (PRN)
Restraints: Application	Detail: Fit allows about two fingers under the strap; tie to the bed frame with a quick-release knot
Restraints: Monitoring	Detail: Circulation, skin, sensation, breathing, hydration, nutrition, toileting, and comfort at policy intervals
Restraints: Release	Detail: Remove as soon as the client is safe; reassess regularly
Restraints: Documentation	Detail: Behavior, alternatives tried, monitoring, and release
Seizure precautions and safe body mechanics: Stay with the client; call for help	After a seizure: Side-lying to drain secretions
Seizure precautions and safe body mechanics: Protect the head; move hazards away	After a seizure: Assess airway, breathing, oxygen saturation
Seizure precautions and safe body mechanics: Time the seizure; note characteristics	After a seizure: Reorient; check for injury
Seizure precautions and safe body mechanics: Do not restrain or put anything in the mouth	After a seizure: Document onset, duration, and behavior
and CKD from the nurse's side: Potassium above 5.0 mEq/L, peaked T waves	Nursing concern: Dysrhythmia risk: cardiac monitor, notify, anticipate treatment
and CKD from the nurse's side: Weight gain, crackles, edema	Nursing concern: Fluid overload: fluid restriction, diuretics or dialysis as ordered
and CKD from the nurse's side: Rising BUN, confusion, itching, nausea	Nursing concern: Uremia
and CKD from the nurse's side: Low hemoglobin	Nursing concern: Anemia from low erythropoietin
and CKD from the nurse's side: High phosphate, low calcium	Nursing concern: Bone and mineral disorder: phosphate binders with meals
Hemodialysis access and care: Hypotension	Clue: Dizziness, cramps, nausea during treatment; Action: Notify dialysis team; position; fluids per protocol
Hemodialysis access and care: Disequilibrium syndrome	Clue: Headache, restlessness, confusion, seizures; Action: Slow or stop per protocol; notify
Hemodialysis access and care: Bleeding	Clue: Prolonged bleeding at needle sites (heparin); Action: Pressure; monitor
Hemodialysis access and care: Infection	Clue: Fever, access redness; Action: Report; aseptic access care
Renal diet and teaching: Potassium	Guidance (as prescribed): Limit; Examples to limit: Bananas, oranges, potatoes, tomatoes, salt substitutes
Renal diet and teaching: Phosphorus	Guidance (as prescribed): Limit; phosphate binders with meals; Examples to limit: Dairy, cola, processed foods
Renal diet and teaching: Sodium	Guidance (as prescribed): Limit; Examples to limit: Processed and canned foods
Renal diet and teaching: Fluid	Guidance (as prescribed): Restrict to prescribed amount; Examples to limit: Count ice, soup, gelatin
Renal diet and teaching: Protein	Guidance (as prescribed): Moderate before dialysis; higher on dialysis; Examples to limit: Emphasize high-quality protein
Risk assessment: Sensory perception	What it measures: Ability to feel and respond to discomfort
Risk assessment: Moisture	What it measures: Exposure of skin to moisture (sweat, urine, stool)
Risk assessment: Activity	What it measures: Degree of physical activity
Risk assessment: Mobility	What it measures: Ability to change and control body position
Risk assessment: Nutrition	What it measures: Usual food intake pattern
Risk assessment: Friction and shear	What it measures: Sliding and dragging during movement
Other complications of immobility: Respiratory	Complication: Atelectasis, pneumonia; Prevention: Turn, cough, deep breathe; incentive spirometry
Other complications of immobility: Cardiovascular	Complication: DVT, orthostatic hypotension; Prevention: Leg exercises, compression devices, gradual position changes
Other complications of immobility: Musculoskeletal	Complication: Contractures, muscle and bone loss; Prevention: Range of motion, positioning, early mobility
Other complications of immobility: System: GI	Complication: Constipation; Prevention: Fluids, fiber, mobility, bowel regimen
Other complications of immobility: Urinary	Complication: Stasis, infection, stones; Prevention: Fluids, avoid unnecessary catheters
Other complications of immobility: Psychosocial	Complication: Isolation, depression, disorientation; Prevention: Interaction, routine, orientation
Taking an accurate blood pressure: Cuff too small (bladder too narrow)	Effect on reading: Falsely high
Taking an accurate blood pressure: Cuff too large	Effect on reading: Falsely low
Taking an accurate blood pressure: Arm below heart level	Effect on reading: Falsely high
Taking an accurate blood pressure: Arm above heart level	Effect on reading: Falsely low
Taking an accurate blood pressure: Back unsupported, legs crossed, talking	Effect on reading: Falsely high
Taking an accurate blood pressure: Deflating the cuff too quickly	Effect on reading: Systolic underestimated, diastolic overestimated
Taking an accurate blood pressure: No rest before measuring; recent caffeine, exercise, or smoking	Effect on reading: Falsely high
Pharmacological therapies: Thiazide diuretic (hydrochlorothiazide)	Key nursing checks: BP, K⁺, glucose; Teach / watch for: Hypokalemia, hyperglycemia, increased uric acid; take in the morning
Pharmacological therapies: ACE inhibitor (lisinopril)	Key nursing checks: BP, K⁺, creatinine; Teach / watch for: Dry cough; angioedema (emergency); avoid in pregnancy; avoid potassium salt substitutes
Pharmacological therapies: ARB (losartan)	Key nursing checks: BP, K⁺, creatinine; Teach / watch for: Hyperkalemia; avoid in pregnancy; less cough than ACE inhibitors
Pharmacological therapies: Calcium channel blocker (amlodipine)	Key nursing checks: BP; HR for verapamil/diltiazem; Teach / watch for: Peripheral edema, flushing, headache; avoid grapefruit juice with some agents
Pharmacological therapies: Beta blocker (metoprolol)	Key nursing checks: Apical HR and BP; Teach / watch for: Bradycardia, fatigue; do not stop abruptly; may mask hypoglycemia signs in diabetes
Rhythms the nurse must know: Sinus bradycardia	Strip features: Regular, rate <60, normal P before each QRS; Priority nursing action: If symptomatic: assess, notify, atropine as ordered; hold rate-slowing drugs per order
Rhythms the nurse must know: Sinus tachycardia	Strip features: Regular, rate >100; Priority nursing action: Treat the cause: pain, fever, hypovolemia, anxiety, hypoxia
Rhythms the nurse must know: Supraventricular tachycardia	Strip features: Regular, narrow QRS, rate often 150–250, P waves hidden; Priority nursing action: Vagal maneuvers, then adenosine rapid IV push with flush, as ordered
Rhythms the nurse must know: Atrial fibrillation	Strip features: Irregularly irregular, no distinct P waves; Priority nursing action: Rate control, anticoagulation, stroke-risk teaching
Rhythms the nurse must know: Premature ventricular contractions	Strip features: Early wide bizarre QRS; Priority nursing action: Check K⁺ and Mg²⁺, oxygenation; report if frequent or new
Rhythms the nurse must know: Ventricular tachycardia	Strip features: Wide QRS, regular, fast; Priority nursing action: Pulse? No: CPR + defibrillate. Yes and unstable: synchronized cardioversion
Rhythms the nurse must know: Ventricular fibrillation	Strip features: Chaotic waveform, no QRS; Priority nursing action: CPR and immediate defibrillation
Rhythms the nurse must know: Asystole	Strip features: Flat line (confirm in two leads); Priority nursing action: CPR and epinephrine; do not shock
Shockable vs non-shockable arrest rhythms: Client has a pulse?	Synchronized cardioversion: Yes; Defibrillation: No
Shockable vs non-shockable arrest rhythms: Timing	Synchronized cardioversion: Shock timed to the R wave; Defibrillation: Unsynchronized
Shockable vs non-shockable arrest rhythms: Used for	Synchronized cardioversion: Unstable SVT, atrial fibrillation or flutter, VT with a pulse; Defibrillation: VF, pulseless VT
Shockable vs non-shockable arrest rhythms: Nursing points	Synchronized cardioversion: Sedation if possible, consent if not emergent; anticoagulation status for atrial fibrillation; Defibrillation: Stand clear; resume CPR right after the shock
Hypothyroidism vs hyperthyroidism: Levothyroxine (hypothyroidism)	Nursing points: Empty stomach, same time daily; separate from calcium, iron, and antacids; lifelong; report signs of overreplacement
Hypothyroidism vs hyperthyroidism: Methimazole (hyperthyroidism)	Nursing points: Report sore throat or fever (agranulocytosis); monitor liver tests
Hypothyroidism vs hyperthyroidism: Propylthiouracil	Nursing points: Often preferred in the first trimester of pregnancy; liver toxicity risk
Hypothyroidism vs hyperthyroidism: Radioactive iodine	Nursing points: Contraindicated in pregnancy; follow radiation safety instructions; hypothyroidism may follow
Hypothyroidism vs hyperthyroidism: Beta blockers	Nursing points: Control tachycardia and tremor
Adrenal disorders: Blood pressure	Addison disease: Low; Cushing syndrome: High
Adrenal disorders: Glucose	Addison disease: Low; Cushing syndrome: High
Adrenal disorders: Sodium	Addison disease: Low; Cushing syndrome: High or normal
Adrenal disorders: Potassium	Addison disease: High; Cushing syndrome: Low
Adrenal disorders: Appearance	Addison disease: Weight loss, bronze skin; Cushing syndrome: Moon face, buffalo hump, central obesity, thin skin, striae
Adrenal disorders: Nursing priority	Addison disease: Fluids, steroid replacement, stress dosing teaching; Cushing syndrome: Infection prevention, glucose and BP control, fall and fracture prevention
Acute treatment timeline: Arrival	Nursing action: Airway, breathing, circulation; neuro assessment (for example, NIH Stroke Scale)
Acute treatment timeline: Glucose	Nursing action: Check early; treat hypoglycemia
Acute treatment timeline: Imaging	Nursing action: Transport for noncontrast CT promptly
Acute treatment timeline: Thrombolysis	Nursing action: Two IV sites; BP below 185/110 before; frequent neuro and BP checks after; bleeding precautions
Acute treatment timeline: After thrombolysis	Nursing action: Report new headache, worsening neuro status, nausea or vomiting (possible bleeding); avoid invasive procedures per protocol
Ongoing care and complications: Dysphagia and aspiration	Nursing care: NPO until swallow screen passed; upright for meals; thickened liquids if ordered; speech-language pathology referral
Ongoing care and complications: Immobility	Nursing care: Turn and position, range of motion, early mobilization when stable, DVT prevention
Ongoing care and complications: Neglect (right-hemisphere stroke)	Nursing care: Approach and teach the client to scan toward the affected side; arrange the environment for safety
Ongoing care and complications: Aphasia (left-hemisphere stroke)	Nursing care: Simple yes/no questions, picture boards, allow time, do not finish sentences
Ongoing care and complications: Homonymous hemianopsia	Nursing care: Place items within the intact visual field; teach head turning to scan
Ongoing care and complications: Falls	Nursing care: Fall precautions; assistive devices; supervised transfers
Respiratory assessment: Crackles (fine or coarse)	What it suggests: Fluid in small airways: pneumonia, heart failure, atelectasis
Respiratory assessment: Wheezes	What it suggests: Narrowed airways: asthma, COPD
Respiratory assessment: Rhonchi	What it suggests: Secretions in larger airways; may clear with coughing
Respiratory assessment: Stridor	What it suggests: Upper-airway obstruction: an emergency
Respiratory assessment: Diminished or absent	What it suggests: Poor air movement, pneumothorax, effusion, or consolidation
Respiratory assessment: Pleural friction rub	What it suggests: Inflamed pleura; grating sound that does not clear with coughing
Suctioning and tracheostomy care: Routine care	Nursing action: Clean the stoma and inner cannula per policy; keep one finger of space under the ties; change ties with a second person holding the tube
Suctioning and tracheostomy care: Cuff	Nursing action: Keep cuff pressure within the ordered range (commonly about 20–30 cm H₂O) to protect the tracheal wall
Suctioning and tracheostomy care: Bedside equipment	Nursing action: Obturator, spare tubes (same size and one size smaller), suction, oxygen, and a bag-valve device
Suctioning and tracheostomy care: Accidental dislodgement	Nursing action: Call for help; with a mature tract, reinsert using the obturator; with a fresh tract (about the first week), oxygenate and ventilate per protocol rather than forcing a tube
Suctioning and tracheostomy care: Cannot pass a suction catheter	Nursing action: Suspect obstruction: remove the inner cannula, then follow the emergency protocol
Assessing pain: Adults able to self-report	Recommended approach: Numeric rating scale 0–10
Assessing pain: Young children (about 3 and older)	Recommended approach: Faces-based scale
Assessing pain: Infants and preverbal children	Recommended approach: Behavioral scale such as FLACC (Face, Legs, Activity, Cry, Consolability)
Assessing pain: Adults with advanced dementia	Recommended approach: Behavioral scale such as PAINAD
Assessing pain: Critically ill, intubated clients	Recommended approach: Behavioral scale such as CPOT
Managing pain: Cold	Notes: Often used in the first 24–48 hours after injury to reduce swelling
Managing pain: Heat	Notes: Muscle spasm and chronic pain; avoid over impaired sensation or bleeding
Managing pain: Positioning and splinting	Notes: Support the painful area; splint incisions to cough
Managing pain: Distraction, music, guided imagery, relaxation	Notes: Useful alone for mild pain and with drugs for more severe pain
Managing pain: Massage	Notes: Avoid over a suspected DVT, open wounds, or fragile skin
Managing pain: TENS	Notes: Electrical stimulation; not over the chest of clients with pacemakers without approval
Therapeutic communication: Open-ended question	Example: "What has been on your mind today?"
Therapeutic communication: Reflecting feelings	Example: "You sound frightened about going home."
Therapeutic communication: Restating or clarifying	Example: "You said nobody listens to you. Tell me more."
Therapeutic communication: Offering self	Example: "I will sit with you for a while."
Therapeutic communication: Silence	Example: Allowing time for the client to think and respond
Therapeutic communication: Presenting reality	Example: "I don't hear voices, but I can see they upset you."
Substance use: alcohol withdrawal: Assess with a withdrawal scale (such as CIWA-Ar) per protocol	Rationale: Guides symptom-triggered benzodiazepine dosing
Substance use: alcohol withdrawal: Benzodiazepines as ordered	Rationale: Prevent and treat seizures and delirium tremens
Substance use: alcohol withdrawal: Thiamine (vitamin B1) as ordered, before glucose-containing fluids	Rationale: Prevents Wernicke encephalopathy (confusion, ataxia, eye movement abnormalities)
Substance use: alcohol withdrawal: Seizure precautions, quiet room, frequent vital signs	Rationale: Safety and early detection
Substance use: alcohol withdrawal: Nutrition, fluids, electrolytes (magnesium, potassium)	Rationale: Malnutrition and losses are common
A five-step method for any strip: Large boxes between R waves: 1	Rate (bpm): 300
A five-step method for any strip: Large boxes between R waves: 2	Rate (bpm): 150
A five-step method for any strip: Large boxes between R waves: 3	Rate (bpm): 100
A five-step method for any strip: Large boxes between R waves: 4	Rate (bpm): 75
A five-step method for any strip: Large boxes between R waves: 5	Rate (bpm): 60
A five-step method for any strip: Large boxes between R waves: 6	Rate (bpm): 50
Lead placement and artifact: White (RA)	Placement: Right upper chest, below the clavicle
Lead placement and artifact: Black (LA)	Placement: Left upper chest, below the clavicle
Lead placement and artifact: Green (RL)	Placement: Right lower abdomen
Lead placement and artifact: Red (LL)	Placement: Left lower abdomen
Lead placement and artifact: Brown (V)	Placement: Chest position, commonly V1 (4th intercostal space, right sternal border)
Types of shock: Hypovolemic	Skin: Cool, pale, clammy; Key clue: Blood or fluid loss; flat neck veins; Priority treatment: Stop bleeding; fluids or blood
Types of shock: Cardiogenic	Skin: Cool, clammy; Key clue: Crackles, JVD, recent MI; Priority treatment: Support the pump; cautious fluids; inotropes as ordered
Types of shock: Septic	Skin: Often warm early, cool later; Key clue: Infection, fever or hypothermia, high lactate; Priority treatment: Antibiotics, fluids, vasopressors
Types of shock: Anaphylactic	Skin: Flushed, hives; Key clue: Exposure; wheeze, stridor, swelling; Priority treatment: IM epinephrine
Types of shock: Neurogenic	Skin: Warm, dry; Key clue: Spinal cord injury; bradycardia; Priority treatment: Fluids, vasopressors, atropine for bradycardia as ordered
Types of shock: Obstructive	Skin: Cool; Key clue: Tracheal shift, muffled heart sounds, sudden dyspnea; Priority treatment: Relieve the obstruction
Sepsis: the first hour: Screen	Detail: New confusion, fever or low temperature, tachypnea, tachycardia, low BP in a client with possible infection
Sepsis: the first hour: Escalate	Detail: Call the rapid response or sepsis team per protocol
Sepsis: the first hour: Monitor	Detail: MAP, urine output, mental status, lactate trend, signs of fluid overload
Sepsis: the first hour: Vasopressors	Detail: Norepinephrine first-line; preferably via central line, watch for extravasation if peripheral
Recognize hypoxia: Poor perfusion, cold fingers	Effect: Unreliable reading; try earlobe or forehead probe
Recognize hypoxia: Dark nail polish, artificial nails	Effect: Can interfere with reading
Recognize hypoxia: Carbon monoxide poisoning	Effect: Falsely normal SpO₂
Recognize hypoxia: Darker skin pigmentation	Effect: Pulse oximeters can overestimate saturation; correlate with ABGs and clinical signs
Recognize hypoxia: Motion	Effect: Artifact
Safety and skin care: Fire	Nursing action: No smoking, candles, or open flames; post signs; avoid petroleum jelly on the face (use water-based lubricant)
Safety and skin care: Tank safety	Nursing action: Secure cylinders upright; store away from heat
Safety and skin care: Pressure injury	Nursing action: Pad tubing over ears; check nares and bridge of nose
Safety and skin care: Dryness	Nursing action: Mouth care; humidify as ordered
Safety and skin care: Oxygen toxicity	Nursing action: Avoid prolonged high FiO₂ beyond what is needed
Recognize and treat opioid toxicity: Step: 1	Nursing action: Stop the opioid (stop any PCA or infusion); stimulate the client
Recognize and treat opioid toxicity: Step: 2	Nursing action: Support the airway and breathing; give oxygen; call for help
Recognize and treat opioid toxicity: Step: 3	Nursing action: Give naloxone as ordered (often diluted and titrated slowly IV in post-op clients to avoid severe pain and withdrawal)
Recognize and treat opioid toxicity: Step: 4	Nursing action: Monitor closely: naloxone may wear off before the opioid, so sedation can return
Recognize and treat opioid toxicity: Step: 5	Nursing action: Notify the provider; document
Side effects and PCA safety: Constipation	Nursing management: Scheduled stimulant laxative (often with a stool softener); fluids, fiber, activity
Side effects and PCA safety: Nausea and vomiting	Nursing management: Antiemetic as ordered; often improves after a few days
Side effects and PCA safety: Urinary retention	Nursing management: Monitor output; bladder scan
Side effects and PCA safety: Orthostatic hypotension, dizziness	Nursing management: Fall precautions; rise slowly
Side effects and PCA safety: Pruritus	Nursing management: Assess; treat as ordered
Peripheral IV complications: Infiltration	Findings: Swelling, coolness, pallor, slowed flow, no blood return; Nursing action: Stop, remove, elevate, restart elsewhere; compress per policy
Peripheral IV complications: Extravasation (vesicant)	Findings: Pain, burning, blanching, blistering; Nursing action: Stop; follow protocol (often aspirate before removing); notify; antidote per protocol
Peripheral IV complications: Phlebitis	Findings: Redness, warmth, tenderness, palpable cord along the vein; Nursing action: Remove catheter; warm compress per policy; restart elsewhere
Peripheral IV complications: Local infection	Findings: Redness, drainage, fever; Nursing action: Remove; culture per policy; notify
Peripheral IV complications: Fluid overload	Findings: Crackles, dyspnea, JVD, rising BP, weight gain; Nursing action: Slow the infusion to keep-open rate, raise head of bed, notify
Peripheral IV complications: Air embolism	Findings: Sudden dyspnea, chest pain, hypotension, confusion; Nursing action: Clamp; left side, head down if tolerated; oxygen; rapid response
Total parenteral nutrition: Hyperglycemia	Clue: Elevated glucose, thirst, polyuria; Action: Monitor glucose; insulin as ordered
Total parenteral nutrition: Rebound hypoglycemia	Clue: Shaky, sweaty after TPN stops; Action: Taper per order; hang dextrose 10% if TPN is unavailable, per policy
Total parenteral nutrition: Refeeding syndrome	Clue: Low phosphate, potassium, magnesium in malnourished clients; Action: Start slowly; monitor and replace electrolytes
Total parenteral nutrition: Infection	Clue: Fever, line-site redness; Action: Aseptic technique; report
Anemia and sickle cell disease: Iron deficiency anemia	Nursing focus: Fatigue, pallor, tachycardia; iron with vitamin C, between meals if tolerated; dark stools are expected; use a straw for liquid iron to protect teeth
Anemia and sickle cell disease: Vitamin B₁₂ deficiency	Nursing focus: Neurologic signs (numbness, balance problems); lifelong injections or high-dose oral B₁₂ if absorption is impaired
Anemia and sickle cell disease: Sickle cell crisis	Nursing focus: Rapid pain control, IV and oral fluids, oxygen if SpO₂ is low, warmth (avoid cold packs), rest
Anemia and sickle cell disease: Acute chest syndrome	Nursing focus: Chest pain, fever, cough, hypoxia, new infiltrate — emergency; notify immediately
Anemia and sickle cell disease: Crisis prevention	Nursing focus: Hydration, avoid cold, high altitude, and strenuous exertion; vaccines; hydroxyurea as prescribed
Blood transfusion and reactions: Acute hemolytic	Cues: Fever, chills, back or flank pain, hypotension, dark urine, sense of doom — usually early
Blood transfusion and reactions: Febrile nonhemolytic	Cues: Fever and chills without hemolysis
Blood transfusion and reactions: Allergic	Cues: Hives, itching; anaphylaxis if severe (wheezing, hypotension)
Blood transfusion and reactions: Circulatory overload (TACO)	Cues: Dyspnea, crackles, hypertension, JVD — sit upright, slow or stop, diuretic as ordered
Blood transfusion and reactions: Lung injury (TRALI)	Cues: Acute respiratory distress and hypoxemia within 6 hours
Deficit vs excess: Vomiting, diarrhea, NG suction, burns, fever, diuretics	Deficit or excess: Deficit
Deficit vs excess: Hemorrhage	Deficit or excess: Deficit (blood loss)
Deficit vs excess: Heart failure, kidney failure, cirrhosis	Deficit or excess: Excess
Deficit vs excess: Excess IV fluid or sodium intake	Deficit or excess: Excess
Deficit vs excess: SIADH	Deficit or excess: Water excess (dilutional hyponatremia)
fluid types: 0.9% sodium chloride	Use: Hypovolemia, blood transfusion, many medications; Caution: Fluid overload in heart or kidney failure; hyperchloremic acidosis with large volumes
fluid types: Lactated Ringer's	Use: Volume replacement, burns, surgery; Caution: Contains potassium and lactate; per provider in some conditions
fluid types: 0.45% sodium chloride	Use: Cellular dehydration, hypernatremia; Caution: Can worsen cerebral edema and hypovolemia
fluid types: 3% sodium chloride	Use: Severe symptomatic hyponatremia; Caution: Close sodium monitoring; avoid overly rapid correction
fluid types: Fluid: D5W	Use: Free water; carrier for some drugs; Caution: Not for resuscitation; can lower sodium
Transmission-based precautions: Contact	Examples: MRSA, VRE, C. difficile, scabies, lice, RSV, draining wounds; PPE and room: Gown and gloves; private room or cohort; dedicated equipment (stethoscope, BP cuff)
Transmission-based precautions: Droplet	Examples: Influenza, pertussis, N. meningitidis, mumps, rubella; PPE and room: Surgical mask when near the client; private room or spatial separation; client masks for transport
Transmission-based precautions: Airborne	Examples: Tuberculosis, measles, varicella, disseminated zoster; PPE and room: Fit-tested N95 (or higher); negative-pressure airborne infection isolation room; door closed
Room assignment and protective precautions: Two clients with the same organism (e.g., both MRSA)	Best choice: May share a room (cohorting) per policy
Room assignment and protective precautions: Client with neutropenia	Best choice: Private room; avoid ill visitors and staff; strict hand hygiene; report fever immediately
Room assignment and protective precautions: Pregnant staff member	Best choice: Avoid assignment to clients with infections risky in pregnancy (for example, rubella, CMV), per policy
Room assignment and protective precautions: Client with suspected TB awaiting results	Best choice: Airborne precautions now, before confirmation
Prioritization rules: Acute vs chronic	Higher priority: New chest pain; Lower priority: Chronic stable angina
Prioritization rules: Unstable vs stable	Higher priority: Falling BP, rising HR; Lower priority: Stable vital signs
Prioritization rules: Unexpected vs expected	Higher priority: Absent pedal pulse after cardiac catheterization; Lower priority: Mild incisional pain after surgery
Prioritization rules: Actual vs potential	Higher priority: Active bleeding; Lower priority: Risk for bleeding
Prioritization rules: Physiological vs psychosocial	Higher priority: Hypoglycemia; Lower priority: Anxiety about discharge
Prioritization rules: Assess vs act	Higher priority: Assess first, unless emergency action is needed now; Lower priority: —
Delegation: the five rights: Examples	Assistive personnel (AP/UAP): Vital signs on stable clients, bathing, feeding, ambulation, I&O, specimen collection, positioning; LPN/VN (varies by state): Care of stable clients, medications other than those restricted by state, wound care, reinforcing teaching, data collection; RN only: Initial assessment, care planning, teaching, evaluation, unstable clients, new admissions, most IV push medications, blood transfusion assessment
Insulin timing and administration: Rapid-acting (lispro, aspart)	Nursing timing point: Give within about 15 minutes of a meal; food must be available
Insulin timing and administration: Regular	Nursing timing point: Give about 30 minutes before a meal; only type given IV for DKA
Insulin timing and administration: NPH (intermediate)	Nursing timing point: Cloudy; roll gently, do not shake; watch for lows at peak (afternoon or overnight)
Insulin timing and administration: Glargine (long-acting)	Nursing timing point: Once daily at the same time; do not mix
vs HHS: Typical client	DKA: Type 1 (can occur in type 2); HHS: Type 2, often older adults
vs HHS: Glucose	DKA: ≥ 200 mg/dL (2024 criteria; classically > 250) or known diabetes; HHS: Usually > 600 mg/dL
vs HHS: Ketones and acidosis	DKA: Present; low pH and bicarbonate; HHS: Minimal or absent
vs HHS: Breathing	DKA: Kussmaul respirations, fruity breath; HHS: Usually normal
vs HHS: Priority	DKA: IV fluids, IV insulin, potassium; HHS: Aggressive IV fluids, insulin, neuro monitoring
Monitoring an IV heparin infusion: aPTT or anti-Xa	What to look for: Above the target range; Action: Adjust per protocol (often pause briefly and reduce rate)
Monitoring an IV heparin infusion: aPTT or anti-Xa	What to look for: Below range; Action: Adjust per protocol (may bolus and increase rate)
Monitoring an IV heparin infusion: Platelets	What to look for: Falling by 50% or more; Action: Suspect HIT; stop heparin and notify
Monitoring an IV heparin infusion: Hemoglobin	What to look for: Falling; Action: Assess for bleeding
Monitoring an IV heparin infusion: Bleeding signs	What to look for: Gums, urine, stool, IV sites, neuro changes; Action: Stop the infusion if serious and notify