NCLEX Fundamentals
89 flashcards by MentisLibrary
The core nursing concepts that show up on every exam and every shift. Prioritization by ABCs and Maslow, safe delegation, infection control and isolation precautions, patient safety, positioning, pressure injury staging and therapeutic communication.
- What are the five steps of the nursing process?
- Assessment, diagnosis, planning, implementation, evaluation
- Why is assessment usually the first correct action?
- Because you cannot choose a safe intervention without data about the current situation
- When is intervention correct before assessment?
- When there is an immediate threat to life, such as absent breathing, active hemorrhage or an unsafe environment
- What does the ABC framework prioritize?
- Airway first, then breathing, then circulation
- Where does disability and exposure fit after ABC?
- They extend the sequence to ABCDE, adding neurologic disability and exposure of the whole body for hidden injury
- How does Maslow's hierarchy guide nursing priorities?
- Physiologic needs come first, then safety, then love and belonging, then esteem, then self actualization
- When a question offers a physiologic and a psychosocial option, which is usually correct?
- The physiologic option, unless every physiologic need is already met or the situation is a psychiatric emergency
- What is the difference between an actual and a risk nursing diagnosis?
- An actual diagnosis describes a problem that exists now, while a risk diagnosis describes vulnerability to a future problem
- What makes a nursing goal measurable?
- It states a specific observable behavior, the conditions, and a time frame
- What are the five rights of delegation?
- The right task, right circumstance, right person, right direction and communication, and right supervision
- Which tasks can never be delegated to unlicensed assistive personnel?
- Assessment, teaching, evaluation, nursing judgment, and care of an unstable patient
- What kinds of tasks are appropriate to delegate to unlicensed assistive personnel?
- Standard, unchanging tasks on stable patients, such as bathing, feeding, ambulating, positioning, and recording intake, output and routine vital signs
- What is SBAR?
- A structured handoff format: situation, background, assessment, recommendation
- What are the components of informed consent?
- Disclosure of the procedure, risks, benefits and alternatives, given voluntarily by a patient with capacity to decide
- What is the nurse's role in informed consent?
- Witnessing the signature, verifying the patient understands, and notifying the provider if the patient has unanswered questions
- What is an advance directive?
- A legal document stating a person's wishes for future care if they lose the ability to decide
- What is the difference between a living will and a durable power of attorney for health care?
- A living will states which treatments the person wants, while a durable power of attorney names a person to decide on their behalf
- What does a do not resuscitate order mean?
- No chest compressions or defibrillation if the heart or breathing stops
- What are the four principles of biomedical ethics?
- Autonomy, beneficence, nonmaleficence and justice
- What is the difference between negligence and malpractice?
- Negligence is failing to act as a reasonable person would, while malpractice is professional negligence by a licensed practitioner
- What is the difference between assault and battery in health care?
- Assault is threatening unwanted contact, while battery is actually carrying it out
- What does HIPAA protect?
- The privacy and security of identifiable health information
- What are the two patient identifiers required before any care?
- Two identifiers that are not the room number, most commonly full name and date of birth
- What is a surgical time out?
- A deliberate pause before a procedure to verify correct patient, correct procedure and correct site
- What does RACE stand for in fire safety?
- Rescue, alarm, contain, extinguish or evacuate
- What does PASS stand for in fire extinguisher use?
- Pull the pin, aim at the base of the fire, squeeze the handle, sweep side to side
- What are the three elements of the fire triangle?
- Oxygen, fuel and heat
- What are the general rules of restraint use?
- Restraints are a last resort, require an order, need the least restrictive type, and demand frequent monitoring and documentation
- What are the most important fall prevention measures?
- Bed in the lowest position, wheels locked, call light and belongings within reach, adequate lighting, nonskid footwear, and clear pathways
- Which patients are at highest risk of falling?
- Older adults, and anyone with confusion, impaired mobility, sensory deficits, urinary urgency, or on sedatives, diuretics or antihypertensives