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Fundamentals of nursing

A nurse is preparing to reposition a 78-year-old bedbound patient who has a Braden Scale score of 12. Which nursing action best prevents pressure injury development over the sacrum?

The full list is below, grouped by blueprint section, so you can scan it without the deck. Each takeaway comes from a question you can practise in context.

Adult Nursing 124

Medical nursingIn hyperosmolar hyperglycemic state, fluid resuscitation comes before insulin — the patient's core problem is profound dehydration.
Medical nursingIn COPD with hypercapnic respiratory failure risk, give oxygen but titrate it to SpO2 88 to 92 percent — never withhold it entirely.
Surgical nursingPerioral tingling plus Trousseau or Chvostek sign after thyroidectomy signals hypocalcemia from parathyroid injury — anticipate IV calcium and watch for laryngospasm.
Mental/psychiatric nursingAsk about suicide directly and specifically — asking does not plant the idea, and plan plus means access defines the level of risk.
Mental/psychiatric nursingIn panic-level anxiety, stay with the patient and give short simple directions — teaching and insight work come only after the acute episode.
Critical care nursingConfirmed cardiac arrest means immediate high-quality compressions — rate 100 to 120/min, depth 5 to 6 cm, full recoil, minimal interruptions.
Critical care nursingTension pneumothorax is a clinical diagnosis — decompress immediately rather than waiting for a chest radiograph.
Community nursingScreening asymptomatic populations for early disease is secondary prevention — primary prevents onset, tertiary limits disability.
Community nursingAttack rate equals cases divided by the population at risk in that group; comparing exposed and unexposed attack rates points to the likely vehicle.
Community nursingFall prevention in older adults combines home hazard removal, strength and balance exercise, and review of fall-risk medications — never mobility restriction.
Mental/psychiatric nursingNeuroleptic malignant syndrome is a medical emergency characterized by hyperthermia, severe muscle rigidity, altered mental status, and autonomic instability in patients taking antipsychotic medications.
Medical nursingIn chronic respiratory acidosis, the kidneys compensate by retaining bicarbonate. If the pH remains outside the normal range despite an elevated HCO3-, the condition is partially compensated. Full compensation returns pH to normal.
Community nursingPrimary prevention strategies, such as health education and lifestyle modification, aim to prevent disease before it occurs by reducing risk factors in the population.
Mental/psychiatric nursingNeuroleptic malignant syndrome (NMS) is a life-threatening reaction to antipsychotics characterized by hyperthermia, severe muscle rigidity, altered mental status, and autonomic instability. Immediate actions include discontinuing the offending drug and activating emergency medical services for transfer to an ICU setting.
Mental/psychiatric nursingWhen a patient appears to be responding to internal stimuli, the nurse's priority is to assess the content of the hallucinations for command or safety risks, using neutral, non-validating language that does not reinforce the hallucination as real.
Critical care nursingIn cardiac arrest with a shockable rhythm (ventricular fibrillation or pulseless ventricular tachycardia) and a defibrillator immediately available, the priority is immediate defibrillation.
Critical care nursingIn inferior STEMI with hypotension, suspect right ventricular infarction. Avoid nitrates and prioritize IV fluid resuscitation to increase preload, while simultaneously preparing for emergent PCI. Vasopressors are second-line if fluids fail.
Community nursingThe attack rate in a foodborne outbreak investigation is the proportion of exposed individuals who become ill, calculated as (number ill among exposed / total exposed) × 100.
Community nursingAt the 2-month well-child visit, the Saudi National Immunization Schedule recommends DTaP, Hib, IPV, PCV, rotavirus, and the second dose of hepatitis B vaccine to protect against diseases during a period of increased susceptibility as maternal antibodies wane.
Critical care nursingIn hypovolemic shock, cool, pale skin is a key sign of peripheral vasoconstriction and inadequate tissue perfusion, reflecting the body's compensatory mechanism to preserve blood flow to vital organs.
Surgical nursingIn a chest drainage system, continuous bubbling in the water seal chamber indicates an air leak, which may be from the patient's pleural space or a system leak. Gentle, continuous bubbling in the suction control chamber of a wet suction system is expected and confirms that suction is being applied. Tidaling (fluid fluctuation) in the water seal chamber is a normal finding.
Surgical nursingEarly ambulation is the most effective nursing intervention to prevent venous thromboembolism in stable postoperative patients.
Mental/psychiatric nursingWhen a patient reports command hallucinations, the nurse's first action is to assess the content of the commands and the patient's intent to follow them, as this determines the immediate risk of harm to self or others and guides safety interventions.
Mental/psychiatric nursingGiving away personal belongings is a critical warning sign of suicidal intent, even when a patient appears calmer; immediate suicide risk assessment is the priority.
Mental/psychiatric nursingPositive symptoms of schizophrenia reflect an excess or distortion of normal functions (e.g., hallucinations, delusions), while negative symptoms reflect a diminution or loss of normal functions (e.g., blunted affect, avolition, social withdrawal).
Surgical nursingMalignant hyperthermia is a life-threatening hypermetabolic crisis triggered by certain anesthetics; the priority intervention is immediate administration of dantrolene.
Critical care nursingIn ARDS, lung-protective ventilation with low tidal volumes (6 mL/kg predicted body weight) reduces mortality and ventilator-induced lung injury.
Medical nursingCurrent guidelines (ACR Manual on Contrast Media, 2023) recommend that metformin can be continued safely in patients with eGFR ≥30 mL/min/1.73 m² and no acute kidney injury, eliminating the need for routine pre-procedural withholding.
Critical care nursingFor extravasation of vasopressors like norepinephrine, the priority nursing action is to stop the infusion immediately and notify the healthcare provider. Phentolamine, an alpha-adrenergic antagonist, is the antidote and should be infiltrated around the extravasation site as soon as possible to prevent ischemic tissue necrosis.
Mental/psychiatric nursingGI symptoms (nausea, vomiting, diarrhea) are early signs of lithium toxicity, while coarse tremor and ataxia indicate moderate toxicity. The nurse's first action is to hold the lithium and notify the healthcare provider for a stat lithium level and further management.
Community nursingIn START triage, red (immediate) tags are for victims with life-threatening but reversible conditions: respiratory rate >30/min, capillary refill >2 seconds, or inability to follow commands. Black tags are for those not breathing after airway repositioning. Green tags are for ambulatory victims with minor injuries. Yellow tags are for non-ambulatory victims with normal respiratory rate, perfusion, and mental status.
Surgical nursingFor wound evisceration, immediately cover the protruding organs with sterile saline-soaked gauze, then place the client in a low Fowler's position with knees bent, and notify the surgeon.
Medical nursingIn acute pancreatitis with hypovolemia, moderate intravenous fluid resuscitation with a balanced crystalloid such as lactated Ringer's is the priority to correct hypovolemia and prevent organ hypoperfusion.
Medical nursingIn hyperkalemia with ECG changes, the immediate priority is to stabilize the cardiac membrane with intravenous calcium (gluconate or chloride) to prevent life-threatening arrhythmias, even before initiating potassium-lowering therapies.
Critical care nursingFor elevated ICP in a patient with a cleared cervical spine, immediate nursing interventions include elevating the head of the bed to 30 degrees and keeping the head midline to promote cerebral venous drainage. Hyperventilation to a PaCO2 of 25–30 mmHg is no longer recommended due to the risk of ischemia; if used temporarily for herniation, target PaCO2 is 30–35 mmHg.
Community nursingFor patients with chronic venous insufficiency, leg elevation above heart level when lying down and consistent daytime use of compression stockings are key strategies to prevent venous ulcers.
Mental/psychiatric nursingClozapine REMS classifies ANC 1,000–1,499/mm³ as mild neutropenia. The drug may be continued, but ANC must be monitored at least weekly until it recovers to ≥1,500/mm³. Interruption is required only for moderate (ANC 500–999) or severe (ANC <500) neutropenia.
Community nursingFor patients with active pulmonary TB who remain sputum smear-positive, the most effective home source control measure is having the patient wear a surgical mask when in shared air spaces. This, along with ensuring adequate ventilation and completing directly observed therapy, helps prevent transmission to household contacts.
Medical nursingLactulose is the first-line therapy for hepatic encephalopathy; it works by acidifying the colon to trap ammonia and promote its excretion.
Surgical nursingUse a bladder scan to confirm urinary retention before considering catheterization in postoperative patients.
Critical care nursingCardiac tamponade presents with Beck's triad (hypotension, muffled heart sounds, distended neck veins) and pulsus paradoxus; prompt recognition and preparation for pericardiocentesis are critical.
Community nursingFor patients with diabetes and peripheral neuropathy, daily foot inspection is the most critical self-care behavior to prevent unrecognized injuries and subsequent complications.
Community nursingClients with diabetes and peripheral neuropathy should avoid prolonged foot soaking, use lukewarm water for brief washing, and dry thoroughly between toes to prevent skin breakdown and infection.
Critical care nursingIn suspected heparin-induced thrombocytopenia, all heparin must be stopped immediately and a non-heparin anticoagulant initiated to prevent life-threatening thrombosis.
Community nursingPursed-lip breathing is a key self-management technique for COPD patients to control dyspnea by prolonging exhalation and reducing air trapping.
Community nursingA healthy colostomy stoma should be pink to red and moist; any color change to dusky or black indicates ischemia and requires immediate medical evaluation.
Mental/psychiatric nursingTardive dyskinesia is a potentially irreversible movement disorder caused by long-term antipsychotic use; early detection using the AIMS and prompt reporting to the provider are essential to prevent progression.
Medical nursingFirst-line therapy for acute pericarditis includes an NSAID (e.g., ibuprofen) plus colchicine to reduce recurrence; opioids are reserved for refractory pain.
Medical nursingIn acute asthma exacerbation, after initiating supplemental oxygen to correct hypoxemia, the next priority is to administer a short-acting beta-agonist (e.g., albuterol) to relieve bronchospasm.
Medical nursingAcute gout flares are managed with colchicine, NSAIDs, or corticosteroids. In patients with a history of peptic ulcer disease, NSAIDs should be avoided due to increased gastrointestinal risk, making colchicine or corticosteroids preferred. Urate-lowering therapies like allopurinol should be continued during an acute flare if already prescribed.
Mental/psychiatric nursingIn serotonin syndrome, the nurse's first action is to withhold the causative serotonergic medications to prevent further accumulation. Supportive measures such as benzodiazepines, cooling, and hydration are secondary and follow discontinuation of the offending agents.
Medical nursingIn anaphylaxis with hypotension or respiratory distress, intramuscular epinephrine into the anterolateral thigh is the immediate priority to prevent progression to shock.
Mental/psychiatric nursingBefore ECT, the nurse must verify that the patient has been NPO for 6–8 hours to reduce the risk of aspiration during anesthesia and the induced seizure.
Mental/psychiatric nursingAntidepressants like fluoxetine take 2–4 weeks to improve mood, but energy may return sooner, potentially increasing suicide risk; patients must be closely monitored and report any suicidal thoughts.
Medical nursingIn acute ischemic stroke, IV alteplase should be administered within 4.5 hours of symptom onset to improve neurological outcomes, after excluding intracranial hemorrhage and other contraindications.
Medical nursingIn suspected digoxin toxicity, the first nursing action is to withhold the drug and notify the healthcare provider to obtain a serum digoxin level and guide specific therapy.
Surgical nursingPostoperative ileus is common after abdominal surgery. Management includes NPO status, nasogastric decompression, and monitoring for return of bowel function (flatus or stool) rather than relying solely on bowel sounds.
Surgical nursingSevere pain unrelieved by analgesia and paresthesia are early signs of compartment syndrome; pallor and delayed capillary refill are late signs. After ensuring no constrictive dressings and maintaining the limb at heart level, immediate surgical notification is essential.
Critical care nursingSerotonin syndrome is a potentially life-threatening condition caused by excess serotonergic activity, often due to drug interactions; key features include clonus, hyperreflexia, and hyperthermia.
Critical care nursingIn septic shock, after initial fluid resuscitation, persistent hypotension requires prompt initiation of vasopressors, with norepinephrine as the first-line agent to achieve a MAP of at least 65 mm Hg.
Community nursingClients with heart failure should report a weight gain of 2 lb or more in one day or 5 lb in one week to their healthcare provider, as this may indicate fluid retention and worsening heart failure.
Mental/psychiatric nursingIn alcohol withdrawal, use the CIWA-Ar scale to objectively assess symptom severity and guide benzodiazepine administration.
Community nursingDaily weight monitoring is a cornerstone of heart failure self-management. A weight gain of 2 pounds or more in a day or 5 pounds in a week indicates fluid retention and should be reported immediately to prevent decompensation.
Mental/psychiatric nursingBenzodiazepines are the first-line pharmacological treatment for alcohol withdrawal syndrome to reduce symptoms and prevent progression to severe withdrawal, including seizures and delirium tremens. Symptom-triggered dosing based on a validated scale (e.g., CIWA-Ar) is recommended. Thiamine is given to prevent Wernicke's encephalopathy but does not treat acute withdrawal. Environmental and safety measures are supportive, not the priority action.
Mental/psychiatric nursingPatients taking MAOIs must avoid tyramine-rich foods (e.g., aged cheeses, cured meats, red wine) to prevent a hypertensive crisis. If such foods are present and the patient has not yet eaten, the nurse's first action is to remove the tray while briefly explaining the reason to maintain therapeutic rapport. Subsequent steps include assessing the patient, providing education, and notifying the provider.
Medical nursingIn a suspected acute hemolytic transfusion reaction, the nurse's first action is to stop the transfusion and maintain IV access with normal saline to prevent further hemolysis and protect renal function.
Critical care nursingIn status epilepticus, administer a benzodiazepine (e.g., lorazepam IV) as the first-line agent to rapidly terminate seizure activity.
Critical care nursingIn critically ill patients with abdominal distension, hypotension, oliguria, and elevated peak airway pressures, suspect abdominal compartment syndrome and measure intra-abdominal pressure via the bladder catheter to confirm the diagnosis.
Community nursingTo prevent catheter-associated infection, always keep the drainage bag below the level of the bladder to avoid urine backflow.
Surgical nursingAfter TURP, suprapubic pain, bladder fullness, and visible clots in the drainage suggest catheter obstruction; the nurse's first action is manual irrigation to clear the catheter and prevent complications such as bladder distension and increased bleeding.
Community nursingFor accurate home blood pressure monitoring, the patient should rest for 5 minutes, sit with back supported and feet flat, keep the arm supported at heart level, and avoid caffeine, exercise, and smoking for 30 minutes prior.
Community nursingClients with a new colostomy should avoid foods that can cause stoma blockage, such as popcorn, nuts, seeds, and corn, until individual tolerance is established.
Critical care nursingFat embolism syndrome classically presents with the triad of respiratory distress, petechiae, and neurological symptoms after a long bone fracture; priority management is supportive care with high-concentration oxygen therapy.
Community nursingTo prevent stoma obstruction, clients with a new ileostomy should chew foods thoroughly and temporarily avoid high-fiber items such as raw vegetables and nuts; these can be gradually reintroduced as tolerated.
Community nursingFor unvaccinated household contacts of a person with hepatitis A, the priority intervention is post-exposure prophylaxis with hepatitis A vaccine or immune globulin within 14 days, as it provides direct protection; hand hygiene and other measures are adjunctive.
Critical care nursingIn ARDS with PaO2/FiO2 < 150 mm Hg and refractory hypoxemia despite lung-protective ventilation, prone positioning improves oxygenation and reduces mortality.
Community nursingAfter pacemaker insertion, patients are often instructed to avoid lifting the affected arm above shoulder level for 1-2 weeks to protect the incision and leads, while heavy lifting (>10 lbs) is restricted for 4-6 weeks. These precautions are provider-specific and may vary with modern lead technology; gentle range-of-motion exercises below shoulder level are encouraged to prevent stiffness.
Mental/psychiatric nursingAcute dystonic reactions, such as oculogyric crisis and torticollis, are extrapyramidal symptoms that can occur within days of starting antipsychotic treatment. They require immediate administration of an anticholinergic agent (e.g., benztropine) to prevent potential airway compromise from laryngeal dystonia.
Medical nursingIn suspected sepsis, obtain blood cultures before administering antibiotics, ensuring timely therapy is not delayed.
Medical nursingIn acute decompensated heart failure, the first nursing priority is to improve oxygenation by giving supplemental O₂ and positioning the patient upright.
Medical nursingIn suspected STEMI, the first nursing intervention is immediate chewed aspirin to inhibit platelet aggregation.
Medical nursingIn acute decompensated heart failure with hypoxemia, the first nursing action is to provide supplemental oxygen to improve tissue oxygen delivery.
Medical nursingIn suspected STEMI, give chewable aspirin immediately; it is the first medication that improves survival before reperfusion.
Medical nursingIn acute STEMI, the first nursing action is to give chewable aspirin promptly to reduce mortality.
Medical nursingHemodynamically unstable atrial fibrillation requires prompt synchronized cardioversion before rate control or anticoagulation.
Medical nursingIn massive pulmonary embolism, the nurse’s first action is to ensure adequate oxygenation and monitor SpO₂ before initiating anticoagulant or thrombolytic therapy.
Medical nursingIn acute heart‑failure‑related pulmonary edema, the first nursing priority is to position the patient semi‑Fowler to decrease preload and enhance breathing.
Surgical nursingWhen signs of opioid‑induced respiratory depression appear, the nurse’s first action is to discontinue the PCA and assess the airway and ventilation.
Surgical nursingSuspected anastomotic leak requires immediate surgeon notification for urgent evaluation.
Surgical nursingSuspected anastomotic leak requires immediate surgeon notification for prompt intervention.
Surgical nursingBedside verification of NG tube placement is done by aspirating gastric contents and confirming a pH ≤5.
Surgical nursingEarly recognition and prompt reporting of signs of an anastomotic leak are critical to prevent sepsis and improve surgical outcomes.
Surgical nursingAny sign of stoma ischemia (dusky color, edema, no output) warrants immediate surgeon notification.
Surgical nursingAdminister low‑molecular‑weight heparin at least 12 hours after epidural catheter removal to reduce the risk of spinal hematoma.
Surgical nursingSigns of an anastomotic leak (fever, tachycardia, abdominal pain/tenderness) require immediate surgeon notification for timely intervention.
Surgical nursingAny sudden change in drain output with systemic signs (fever, tachycardia, abdominal pain) warrants immediate surgeon notification for possible anastomotic leak.
Community nursingMen 65‑75 who have ever smoked should receive a one‑time abdominal ultrasound to screen for AAA, a key secondary‑prevention measure in community nursing.
Community nursingIn the 5 A's smoking‑cessation framework, the first step is to Ask about tobacco use before moving on to Advise, Assess, Assist, and Arrange.
Community nursingUse the 5 A's brief intervention plus nicotine‑replacement therapy to maximize smoking‑cessation success in community settings.
Community nursingDistributing naloxone kits with education is a key community‑based strategy to prevent opioid‑related deaths.
Community nursingA PHQ‑9 score ≥10 in a postpartum woman warrants immediate referral to a mental‑health provider for assessment and possible treatment.
Community nursingAn isolated elevated BP reading in the community should be reconfirmed and addressed with lifestyle counseling before initiating medication, unless a hypertensive emergency is suspected.
Community nursingEnsuring correct inhaler technique, including spacer use and breath‑hold, is the first‑line strategy for effective asthma management in the community.
Mental/psychiatric nursingAtypical antipsychotics can precipitate metabolic syndrome; obtain baseline and periodic glucose, lipid, and weight measurements and report abnormalities promptly.
Mental/psychiatric nursingWhen a patient starts an atypical antipsychotic, the nurse should regularly assess weight, waist circumference, and blood pressure to detect early metabolic syndrome.
Mental/psychiatric nursingWhen valproic acid levels exceed the therapeutic range and labs show hepatic or platelet abnormalities, the nurse should hold the drug and notify the provider promptly.
Mental/psychiatric nursingBegin with verbal de‑escalation; restraints and medication are reserved for when non‑pharmacologic measures fail.
Mental/psychiatric nursingIn acute mania, the nurse’s first action is to ensure safety by creating a low‑stimulus environment and preventing the patient from injuring himself or others.
Mental/psychiatric nursingAkathisia is most effectively managed with beta‑blockers (e.g., propranolol) or benzodiazepines; avoid increasing antipsychotic dose or using restraints.
Mental/psychiatric nursingClozapine can cause myocarditis; early signs require immediate drug discontinuation and provider notification.
Mental/psychiatric nursingIn acute manic episodes with agitation, fast‑acting antipsychotics (e.g., haloperidol) are the priority before mood stabilizers take effect.
Mental/psychiatric nursingWhen initiating second‑generation antipsychotics, obtain baseline weight/BMI (and later monitor weight, glucose, lipids, and blood pressure) to detect metabolic syndrome early.
Medical nursingIn acute decompensated heart failure, the initial nursing priority is to place the patient in a high‑Fowler (45°) position to quickly improve oxygenation and reduce pulmonary congestion.
Medical nursingIn a hemodynamically stable acute pulmonary embolism without contraindications, a direct oral anticoagulant (e.g., rivaroxaban) can be initiated as the first therapeutic anticoagulant; LMWH or UFH are alternatives but are not preferred first‑line agents per current guidelines.
Surgical nursingWhen pulmonary embolism is suspected post‑operatively, the nurse’s priority is to ensure adequate oxygenation and airway support before any diagnostic or therapeutic interventions.
Medical nursingIn severe symptomatic hyponatremia (serum Na <120 mEq/L with neurologic signs), the priority is rapid correction with 3% hypertonic saline; fluid restriction and diuretics are adjuncts once the patient is stabilized.
Surgical nursingA respiratory rate below 10 breaths per minute after epidural analgesia signals respiratory depression or high spinal block and requires rapid intervention to secure the airway and support ventilation.
Surgical nursingWhen a surgical site infection is suspected, the nurse should obtain a culture and notify the surgeon before any other interventions.
Surgical nursingWhen a postoperative surgical drain stops draining, the nurse should first assess the drain system for kinks, blockage, or loss of suction before notifying the surgeon.
Surgical nursingAfter total hip arthroplasty, maintain hip flexion ≤90°, avoid adduction and internal rotation, and keep feet flat on the floor to prevent prosthetic dislocation.
Community nursingIn the 5 A’s model, after confirming a client’s readiness to quit, the nurse should first give clear, personalized advice (Advise) before moving on to assessment, assistance, and arrangement of follow‑up.
Surgical nursingBoth deep‑breathing/coughing exercises and incentive spirometry can help prevent postoperative atelectasis when combined with adequate pain control; encouraging deep breathing with analgesia is the primary evidence‑based intervention.
Community nursingUSPSTF (2021) recommends colorectal cancer screening for average‑risk adults ages 45‑75; an annual FIT is a validated, non‑invasive option that can be offered first when patients prefer a home‑based test.
Community nursingEffective community nursing for hypertension includes teaching accurate home BP measurement, addressing medication‑adherence barriers, and providing prompt follow‑up.

Maternal-Child Nursing 61

Maternity nursingFor a boggy fundus with heavy bleeding, massage the uterus first — it is the fastest way to restore tone. Then empty the distended bladder, which displaces the uterus and keeps it from contracting effectively.
Pediatric medicalSafe infant sleep: supine, firm flat separate surface, nothing soft in the sleep space, room-share but do not bed-share.
Pediatric medicalNever inspect the throat or place anything in the mouth of a child with suspected epiglottitis — keep them calm, upright, and near airway equipment.
Maternity nursingOxytocin is the first-line uterotonic for postpartum hemorrhage due to uterine atony, and intravenous administration is recommended for active hemorrhage to achieve rapid uterine contraction.
Neonatal nursingAn axillary temperature of 36.0°C (96.8°F) in a newborn indicates cold stress, which can lead to hypoglycemia and metabolic acidosis; immediate warming and further evaluation are necessary.
GynecologyLaparoscopy with biopsy is the gold standard for diagnosing endometriosis, particularly in patients with infertility and classic physical examination findings.
GynecologyAfter ruling out pregnancy and significant anemia, transvaginal ultrasound is the first-line imaging modality for evaluating abnormal uterine bleeding and suspected structural abnormalities such as uterine fibroids.
Neonatal nursingIn newborns with risk factors for hypoglycemia (e.g., maternal diabetes, LGA), signs such as jitteriness, weak cry, or lethargy warrant immediate blood glucose assessment to confirm and treat hypoglycemia promptly.
Pediatric medicalEarly signs of respiratory distress in children include tachypnea and wheezing; retractions, nasal flaring, and grunting indicate moderate distress, while cyanosis, decreased breath sounds, and bradycardia are late signs.
Maternity nursingWhen the uterus is firm but bleeding persists, suspect a genital tract laceration; the nurse should first inspect the perineum and apply direct pressure as a temporary measure to control bleeding, then notify the provider.
Pediatric surgicalIn suspected appendicitis requiring surgery, the priority nursing intervention is to maintain NPO status to reduce aspiration risk. Early opioid analgesia is safe and does not mask clinical signs, but NPO status takes precedence. Heat application is contraindicated because it increases inflammation and may worsen the condition.
Neonatal nursingAsymptomatic neonatal hypoglycemia is often managed initially with enteral feeding to raise blood glucose, reserving IV dextrose for symptomatic or severe cases.
Pediatric surgicalPreoperative correction of dehydration and electrolyte imbalances is critical in infants with pyloric stenosis to ensure safe anesthesia and surgery.
Neonatal nursingIn a jaundiced neonate, always obtain a bilirubin level (transcutaneous or serum) and interpret it using hour-specific thresholds that consider gestational age and neurotoxicity risk factors, as per the 2022 AAP guideline, before deciding on management.
Neonatal nursingSymptomatic neonatal hypoglycemia (glucose <40 mg/dL) is a medical emergency requiring prompt intravenous dextrose administration. The nurse's first action is to establish IV access and administer dextrose as prescribed to prevent neurological damage. Asymptomatic newborns with low glucose may be managed with feeding and monitoring.
Pediatric medicalIn infants with bronchiolitis, nasopharyngeal suctioning is a priority intervention to clear secretions and relieve airway obstruction, as infants are obligate nasal breathers. Oxygen is reserved for saturations persistently below 90%.
GynecologyCombined hormonal contraceptives are contraindicated in women with migraines with aura due to an elevated risk of ischemic stroke.
Maternity nursingRespiratory depression (rate <12/min) is a key sign of magnesium sulfate toxicity. The nurse should stop the infusion, notify the provider, and prepare to administer calcium gluconate as the antidote.
Maternity nursingSigns of magnesium sulfate toxicity include respiratory depression (<12/min), loss of deep tendon reflexes, and decreased urine output. The priority nursing actions are to stop the infusion, administer oxygen, and notify the provider immediately.
Pediatric medicalIn acute asthma exacerbations, inhaled short-acting beta-agonists are the first-line intervention for rapid bronchodilation. Supplemental oxygen is reserved for SpO2 < 90%.
GynecologyPostmenopausal bleeding requires evaluation; an endometrial thickness >4 mm on transvaginal ultrasound makes endometrial biopsy the first-line diagnostic step to exclude hyperplasia or carcinoma.
Maternity nursingWhen late decelerations are associated with oxytocin-induced tachysystole, the priority nursing action is to discontinue the oxytocin infusion to reduce uterine activity and improve placental perfusion. Additional interventions such as maternal repositioning and oxygen administration (if maternal hypoxia is present) may be implemented concurrently.
GynecologyFor women aged 25 and older with ASC-US on Pap test, reflex high-risk HPV testing is the preferred triage method. If HPV testing is unavailable, repeat cytology in 1 year is an acceptable alternative.
GynecologyPolycystic ovary syndrome is diagnosed when at least two of the three Rotterdam criteria are present (oligo/anovulation, clinical/biochemical hyperandrogenism, polycystic ovaries on ultrasound) after excluding other causes such as nonclassic congenital adrenal hyperplasia (elevated 17-hydroxyprogesterone) and thyroid dysfunction.
GynecologyAccording to USPSTF guidelines, cervical cancer screening should begin at age 21 with cytology alone every 3 years for average-risk women. HPV testing (alone or co-testing) is not recommended before age 30.
Pediatric medicalNephrotic syndrome is characterized by massive proteinuria, hypoalbuminemia, and edema. Hyperlipidemia is a common associated finding due to altered lipid metabolism. Blood pressure is typically normal, and urine is frothy but not grossly bloody.
GynecologyEmpiric antibiotic therapy for pelvic inflammatory disease should be initiated promptly based on clinical criteria to prevent long-term sequelae such as infertility, ectopic pregnancy, and chronic pelvic pain.
GynecologyBacterial vaginosis is diagnosed by the presence of clue cells on wet mount, elevated vaginal pH, and a positive whiff test, and is treated with oral metronidazole.
Neonatal nursingFor newborns with neonatal abstinence syndrome, non-pharmacological comfort measures (swaddling, low stimulation, small frequent feedings) are the first-line interventions to manage withdrawal symptoms.
Maternity nursingSigns of chorioamnionitis (maternal fever, foul-smelling amniotic fluid, maternal and fetal tachycardia) require immediate provider notification to initiate timely treatment and prevent maternal and neonatal complications.
Pediatric medicalIntussusception is the most common cause of intestinal obstruction in infants and toddlers aged 6 months to 3 years, presenting with intermittent colicky pain, currant jelly stools, and a sausage-shaped mass.
Pediatric surgicalSigns of peritonitis (rigidity, distension, rebound tenderness) contraindicate pneumatic reduction of intussusception because of the high risk of perforation; immediate surgical consultation is required.
GynecologyThe CDC 2021 STI Treatment Guidelines recommend a triple-therapy outpatient regimen for pelvic inflammatory disease: a single intramuscular dose of ceftriaxone 500 mg (or 1 g if weight ≥150 kg) plus oral doxycycline 100 mg twice daily for 14 days plus oral metronidazole 500 mg twice daily for 14 days.
Neonatal nursingAssessment is the priority nursing action for a newborn with suspected neonatal opioid withdrawal syndrome. Validated tools such as the Finnegan Neonatal Abstinence Scoring System or the Eat, Sleep, Console (ESC) approach are used to evaluate withdrawal severity and guide care, with non-pharmacologic interventions as the first-line treatment.
Pediatric medicalFor mild croup (stridor only with agitation), the priority intervention is a single dose of oral dexamethasone to reduce airway edema and prevent progression.
Pediatric medicalFor children 6–23 months with unilateral, non-severe AOM and reliable parents who prefer to avoid antibiotics, the nurse's role is to educate about watchful waiting with pain management and ensure close follow-up, supporting antimicrobial stewardship and shared decision-making.
GynecologyFor symptomatic uterine fibroids in women who desire future fertility, myomectomy is the preferred surgical treatment as it preserves the uterus.
GynecologyThe copper intrauterine device is the most effective emergency contraceptive method and can be inserted up to 5 days after unprotected intercourse, offering ongoing contraception.
Neonatal nursingIn a newborn with risk factors for sepsis (e.g., prolonged rupture of membranes), subtle signs like temperature instability, lethargy, and weak cry should prompt immediate notification of the provider and preparation for a septic workup, as early treatment is critical to prevent serious complications.
Pediatric surgicalIn gastroschisis, the immediate priority is to cover the exposed bowel with warm, sterile, saline-soaked gauze and plastic wrap to prevent heat and fluid loss and reduce infection risk.
Maternity nursingIn shoulder dystocia, the primary nursing intervention is to assist the mother into McRoberts position (sharp flexion of thighs onto abdomen) to maximize pelvic dimensions. Fundal pressure must be avoided.
Maternity nursingPostpartum endometritis typically presents with fever, foul-smelling lochia, and uterine tenderness, requiring prompt antibiotic therapy.
Maternity nursingBetamethasone is a corticosteroid administered to women in preterm labor between 24 0/7 and 33 6/7 weeks gestation to accelerate fetal lung maturity and reduce the risk of neonatal respiratory distress syndrome.
Maternity nursingWhen preterm premature rupture of membranes is suspected, the nurse's first action is to assess fetal well-being by auscultating the fetal heart rate. Digital cervical examinations should be avoided to reduce the risk of infection.
GynecologyIn a hemodynamically stable patient with suspected ectopic pregnancy, the nurse should anticipate and prepare the patient for transvaginal ultrasound to determine pregnancy location.
Neonatal nursingA positive Ortolani sign in a newborn indicates hip instability and possible developmental dysplasia of the hip (DDH). The nurse should promptly notify the healthcare provider to initiate appropriate evaluation and management.
Neonatal nursingIn CCHD pulse oximetry screening, a preductal-postductal saturation difference of ≤3% with both values ≥95% is considered a pass (screen negative) and requires only documentation. The term 'pass' is preferred over 'normal' because a passed screen does not rule out all forms of CCHD.
Pediatric surgicalIn a child with a suspected Wilms tumor, the priority nursing action is to prevent palpation of the abdomen to avoid tumor rupture and seeding of malignant cells. Instruct parents and staff to avoid touching the mass.
GynecologyPelvic floor muscle exercises are the first-line treatment for stress urinary incontinence.
Neonatal nursingCephalohematoma increases the risk of neonatal jaundice due to red blood cell breakdown; therefore, monitoring for hyperbilirubinemia is essential.
Pediatric medicalAfter rehydration in acute gastroenteritis, resume an age-appropriate unrestricted diet immediately to promote gut recovery and prevent malnutrition.
Pediatric surgicalHirschsprung-associated enterocolitis is a serious, potentially fatal complication that can occur even after corrective surgery. Signs include fever, abdominal distension, explosive diarrhea, and lethargy. The nurse must recognize these signs and notify the physician immediately for emergency management.
Maternity nursingMastitis management includes continued breastfeeding to promote milk flow and prevent stasis, with emphasis on effective drainage of the affected breast. Antibiotics are indicated for systemic symptoms; provider notification is essential.
Maternity nursingEpigastric or right upper quadrant pain in a client with preeclampsia suggests hepatic capsular distention and is a sign of progression to preeclampsia with severe features, requiring immediate provider notification.
GynecologyUncomplicated vulvovaginal candidiasis is diagnosed by clinical presentation, normal vaginal pH, and visualization of pseudohyphae on wet mount, and is treated with a single dose of oral fluconazole or a short course of topical azole.
Neonatal nursingErb's palsy (C5-C6 injury) presents with the arm adducted and internally rotated, elbow extended, forearm pronated, and an asymmetric Moro reflex, often following shoulder dystocia.
Pediatric medicalDuring a febrile seizure, place the child on their side, clear the area of dangerous objects, and do not restrain or put anything in the mouth.
Pediatric surgicalIn suspected esophageal atresia/tracheoesophageal fistula, the priority nursing intervention is to prevent aspiration by keeping the infant NPO, elevating the head, and providing continuous suction of the blind esophageal pouch (e.g., with a Replogle tube) to clear secretions and protect the airway.
Maternity nursingIn cord prolapse, the nurse's first action is to manually elevate the presenting part to relieve cord compression, followed by positioning and emergency notification.
Neonatal nursingNewborns with cleft palate often have difficulty generating suction for effective feeding. Specialized feeders that deliver milk by compression, such as the Haberman feeder, can allow oral feeding without the need for suction.
Neonatal nursingTransient tachypnea of the newborn (TTN) is a common cause of respiratory distress in term or late preterm infants, especially after cesarean delivery without labor, due to delayed absorption of fetal lung fluid.

Nursing Fundamentals 37

Fundamentals of nursingPressure injury prevention relies on offloading (30-degree tilt), support surfaces, and moisture control — never massage over bony prominences and never use donut devices.
Physical assessmentUrine output below 0.5 mL/kg/hr is a direct marker of end-organ hypoperfusion, unlike compensatory changes in heart rate or respiratory rate. Three hours of oliguria is a perfusion warning, not an acute kidney injury stage — KDIGO stage 1 requires that low output be sustained for at least 6 hours.
Fundamentals of nursingIn suspected aspiration during enteral feeding, stop the feed first, then protect the airway with side-lying positioning, suction, and oxygen — remove the source of harm before any diagnostic step.
PharmacologyVancomycin infusion reaction is rate-dependent histamine release, not a true allergy — stop, treat with antihistamine, then infuse more slowly.
PharmacologyDose calculation: (desired dose / available dose) x volume on hand — always double-check the units on the supplied concentration.
PharmacologyAn INR of 4.5 to 10 without bleeding is managed by holding warfarin and rechecking the INR, not by giving vitamin K. Low-dose oral vitamin K is considered once the INR exceeds 10, and four-factor PCC plus IV vitamin K is reserved for major bleeding.
Physical assessmentNever measure blood pressure on an arm with an arteriovenous fistula; use the opposite arm to prevent thrombosis and preserve vascular access.
Fundamentals of nursingWhen hands are visibly soiled, wash with soap and water rather than using alcohol-based hand rub.
Fundamentals of nursingHand washing with soap and water is essential after caring for patients with C. difficile infection because alcohol-based hand rubs do not kill spores.
Fundamentals of nursingHand hygiene is the single most important practice to reduce the transmission of infectious agents in healthcare settings and must be performed before and after every patient contact or procedure.
PharmacologyInsulin glargine is a long-acting analog that is a clear solution and must not be mixed with other insulins; administer separate injections.
PharmacologyAcute dystonic reactions to antipsychotics are treated immediately with anticholinergic agents such as benztropine; intravenous administration is preferred for rapid reversal, especially when airway compromise is possible.
Fundamentals of nursingSuspected or confirmed pulmonary tuberculosis requires immediate airborne precautions: a negative-pressure isolation room with ≥12 air changes per hour (existing facilities) and use of a fit-tested N95 respirator for all healthcare personnel entering the room.
Fundamentals of nursingThe 1-inch border of a sterile field is considered unsterile. Sterile items must be placed only on the sterile area to maintain asepsis.
PharmacologyWhen a mixture of NPH and regular insulin is prescribed, the first step is to gently roll the NPH vial between the palms to resuspend the insulin without creating foam or bubbles, which can cause inaccurate dosing. Then inject air into the NPH vial, then the regular vial, and draw up the regular insulin first to prevent contamination. Note: Current guidelines often recommend separate injections to ensure predictable absorption, but this procedure is used when a mixture is specifically prescribed.
PharmacologyWhen mixing insulins, always draw up the clear (regular) insulin first to avoid contaminating the multi-dose vial. Premixed insulin formulations are preferred when available to minimize preparation errors.
Fundamentals of nursingHand hygiene after contact with wound dressings or other potentially infectious materials is classified as 'after body fluid exposure risk,' even if gloves were worn, to prevent cross-contamination.
Fundamentals of nursingAbdominal x-ray is the most reliable method to confirm initial nasogastric tube placement before first use; auscultation and pH testing alone are insufficient.
Physical assessmentDependent rubor is a key sign of severe peripheral arterial disease, reflecting maximal vasodilation in ischemic tissue. In contrast, venous insufficiency typically presents with edema, hemosiderin staining, and irregular ulcers.
Physical assessmentUnilateral leg swelling is a key physical finding for DVT; Homan's sign is unreliable and should not be used as a sole diagnostic indicator.
Physical assessmentElevate the head of the bed to 30-45 degrees to properly assess jugular venous distention; a flat position can cause false-positive findings.
PharmacologyEarly signs of digoxin toxicity include gastrointestinal symptoms (anorexia, nausea, vomiting) and visual disturbances (yellow-green halos). The nurse should withhold the drug and notify the prescriber immediately.
Basic sciencesIn acute respiratory acidosis, the pH is low, PaCO₂ is high, and HCO₃⁻ is normal because renal compensation takes hours to days.
PharmacologyFor intravenous aminoglycosides, the peak level is drawn 30 minutes after the infusion ends to assess therapeutic concentration; the trough level is drawn immediately before the next dose to monitor for toxicity.
Fundamentals of nursingDuring a generalized tonic-clonic seizure, the nurse's first priority is to protect the patient from physical injury by clearing the area of hazards and protecting the head, rather than inserting objects into the mouth, restraining, or administering medication.
Physical assessmentShifting dullness is a sensitive and specific percussion sign for ascites, relying on the movement of free fluid with gravity.
PharmacologyAlways remove the old transdermal patch, clean the skin, and rotate application sites to prevent drug overdose and local skin reactions.
Basic sciencesHypertonic solutions (e.g., 3% NaCl) are used to treat cerebral edema by creating an osmotic gradient that draws water out of brain cells.
Basic sciencesPost-thyroidectomy hypocalcemia due to parathyroid injury presents with neuromuscular irritability, including paresthesias and positive Trousseau's sign.
Basic sciencesPersistent vomiting leads to metabolic alkalosis due to loss of gastric acid (HCl), resulting in elevated pH and HCO₃⁻.
Basic sciencesIn metabolic acidosis, the primary change is a decreased HCO₃⁻ causing a low pH, and the respiratory system compensates by lowering PaCO₂ through hyperventilation.
Basic sciencesHypokalemia typically causes a prominent U wave on ECG, while hyperkalemia causes peaked T waves.
Physical assessmentAsterixis is a sign of metabolic encephalopathy, often hepatic, characterized by brief lapses of postural tone when the patient maintains wrist dorsiflexion. It is not a tremor but a negative myoclonus.
Physical assessmentPleural effusion reduces breath sounds and tactile fremitus due to fluid insulating the lung, while lobar pneumonia increases sound transmission through consolidated tissue, causing bronchial breath sounds, egophony, and whispered pectoriloquy.
Physical assessmentBrudzinski's sign is a screening maneuver for meningeal irritation: passive neck flexion triggers involuntary hip and knee flexion. It has low sensitivity in adults, so a negative sign does not rule out meningitis.
PharmacologyTo prevent tolerance, transdermal nitroglycerin patches should be removed for 10–12 hours daily, typically at night, providing a nitrate-free interval.
PharmacologyWhen applying a nitroglycerin transdermal patch, wear gloves to prevent self-absorption, rotate sites to avoid skin irritation, and never massage the patch.

Nursing Management and Leadership 34

Resources to support and coordinate patient careTriage follows airway, breathing, circulation — stridor with progressing angioedema outranks every stable injury in the queue.
Quality and safe patient care at the frontlineAlways use two patient-specific identifiers — never room or bed number — and ask open-ended identifying questions.
Resources to support and coordinate patient careAssign stable patients with predictable outcomes to LPNs, while reserving RNs for initial assessments, unstable patients, and complex education.
Research and Evidence Based PracticeIn evidence-based practice, systematic reviews of randomized controlled trials (RCTs) represent the highest level of evidence for evaluating intervention effectiveness, as they synthesize findings from multiple studies to provide more reliable conclusions than single studies.
Nursing informatics for safe and legal delivery of patient careIn electronic health records, never delete or alter original entries. Use an addendum to make corrections, clearly noting the error, the correct information, and the date/time of the correction to maintain a complete, legal audit trail.
Quality and safe patient care at the frontlineA near miss is a patient safety event that did not reach the patient and is a valuable opportunity for system improvement without patient harm.
Resources to support and coordinate patient careUAP can be delegated routine tasks for stable patients, such as assisting with ambulation, after the nurse has assessed the patient and confirmed the UAP's competence. Tasks requiring assessment, teaching, or aseptic technique must be performed by licensed nurses.
Quality and safe patient care at the frontlineIn a just culture, near-miss events are reported through incident reporting systems to analyze system vulnerabilities and prevent future errors, without immediate blame.
Nursing teams and interprofessional relationsWhen a nurse reports disruptive behavior, the manager's first action is to provide support and follow the facility's established process for reporting and addressing such behavior, rather than avoiding the issue, expecting the nurse to confront the individual, or immediately confronting the physician without due process.
Nursing informatics for safe and legal delivery of patient careWhen a documentation error involves the wrong patient, the nurse must correct the erroneous entry in the wrong chart by marking it as 'entered in error' (or per facility policy) to preserve audit integrity and prevent clinical misuse, then document the information in the correct chart, and notify a supervisor or privacy officer to address the potential breach of protected health information.
Nursing informatics for safe and legal delivery of patient careWhen a security breach such as sharing login credentials is observed, the first action is to immediately stop the unauthorized access to protect patient confidentiality and comply with HIPAA. Reporting should follow promptly.
Resources to support and coordinate patient careA wound, ostomy, and continence (WOC) nurse provides specialized education and support for patients with new ostomies, promoting self-care and a smooth transition to home.
Resources to support and coordinate patient careSocial workers are essential resources for addressing financial barriers and connecting patients with medication assistance programs and community support.
Research and Evidence Based PracticeIn a PICOT question, the 'I' stands for Intervention, which is the new treatment or approach being evaluated for its effectiveness.
Research and Evidence Based PracticeQuasi-experimental designs lack random assignment, making them less rigorous than RCTs but still useful for evaluating interventions when randomization is not feasible.
Nursing teams and interprofessional relationsWhen managing conflict, the nurse leader's first action is to stop the disruptive behavior to ensure a safe environment, then facilitate a private discussion to resolve the issue.
Research and Evidence Based PracticeIn a PICOT question, the 'O' stands for Outcome, which is the measurable result of interest (e.g., incidence of pressure injuries).
Nursing informatics for safe and legal delivery of patient careWhen an electronic health record allergy alert conflicts with patient-reported information, the nurse must hold the medication and clarify the allergy status with the prescriber to ensure safe, evidence-based care.
Resources to support and coordinate patient careA speech-language pathologist is the appropriate resource for evaluating and managing dysphagia to prevent aspiration and coordinate safe oral intake.
Quality and safe patient care at the frontlineFailure mode and effects analysis (FMEA) is a proactive risk assessment tool used to anticipate and prevent errors before they occur.
Quality and safe patient care at the frontlineRoot cause analysis (RCA) is a systematic process for identifying the fundamental system-based causes of errors, not for assigning individual blame, with the goal of preventing recurrence.
Nursing teams and interprofessional relationsNurse leaders promote interprofessional collaboration by facilitating open dialogue that helps team members identify common goals and reach consensus.
Research and Evidence Based PracticeThe evidence-based practice process follows the 5 A's: Ask, Acquire, Appraise, Apply, and Assess. After formulating a PICOT question, the next step is to acquire the best available evidence.
Research and Evidence Based PracticeIn research ethics, respect for persons demands that participants have the right to withdraw at any time without penalty or loss of entitled benefits, and this must be clearly communicated during the informed consent process.
Research and Evidence Based PracticeThe Institutional Review Board (IRB) exists to safeguard the rights, dignity, and safety of human research participants, and all research involving human subjects must receive IRB approval before commencing.
Research and Evidence Based PracticeInformed consent is an ongoing process of communication that ensures the participant understands the study and voluntarily agrees, not just signing a form.
Research and Evidence Based PracticeMember checking is a technique used in qualitative research to enhance credibility by verifying findings with participants.
Nursing informatics for safe and legal delivery of patient careNurses must use facility-approved secure methods for capturing and transmitting protected health information to ensure compliance with privacy regulations and organizational policies.
Nursing informatics for safe and legal delivery of patient careWhen a BCMA system generates a mismatch alert, the nurse must first verify the medication order in the electronic health record. If the order is missing or incorrect, the prescriber should be contacted for clarification before proceeding.
Research and Evidence Based PracticeThe evidence-based practice process follows five sequential steps: Ask a focused clinical question, Acquire the best evidence, Appraise the evidence, Apply the evidence in practice, and Assess the outcomes.
Quality and safe patient care at the frontlineThe time-out is a critical safety step performed immediately before a non-emergent invasive procedure; any team member must stop the process if it is missed to verify correct patient, procedure, and site.
Quality and safe patient care at the frontlineIn the PDSA cycle, the Study step focuses on analyzing data collected during the Do phase to evaluate the change's impact, often using run charts or control charts rather than inferential statistics, and to identify any unintended consequences before deciding on the next action.
Resources to support and coordinate patient careThe case manager is responsible for coordinating complex discharge plans, arranging post-discharge services, and managing insurance authorizations to ensure a safe transition from hospital to home.
Nursing teams and interprofessional relationsUAPs can perform routine tasks that do not require nursing judgment, such as measuring vital signs for stable patients. Tasks involving medication administration, initial ambulation with specific precautions, or sterile procedures must be performed by licensed nurses.