National Council Licensure Examination for Registered Nurses (NCLEX-RN) Physiological Integrity: Reduction of Risk Potential Flashcards

24 sample cards from the Physiological Integrity: Reduction of Risk Potential deck

Sampled from the end of the deck, so these are different cards from the ones shown on the syllabus page.

1. How should a 24-hour urine collection be started and handled?

   Discard the first void to start timing, then collect all urine for 24 hours (including the final void), keeping the specimen on ice/refrigerated.

2. What is the proper technique for collecting a midstream clean-catch urine specimen?

   Clean the meatus, begin voiding into the toilet, then catch the middle portion in a sterile container to reduce contamination.

3. How should blood cultures be collected to maximize accuracy?

   Draw from two different sites before starting antibiotics, using sterile technique to avoid contamination and detect true bacteremia.

4. What patient prep is required before a fecal occult blood test (guaiac)?

   Avoid red meat, NSAIDs, vitamin C, and certain vegetables for several days to prevent false results.

5. What are the normal adult vital sign ranges (temp, HR, RR, BP)?

   Temp ~98.6F/37C; HR 60–100 bpm; RR 12–20/min; BP <120/80 mmHg (normal).

6. What CVP (central venous pressure) range is normal, and what does a high CVP indicate?

   Normal CVP is 2–8 mmHg; elevated CVP indicates fluid overload or right-heart failure, while low CVP suggests hypovolemia.

7. What is MAP, the formula, and the minimum needed for organ perfusion?

   Mean arterial pressure = (SBP + 2 x DBP)/3; a MAP of at least 60–65 mmHg is needed to perfuse vital organs.

8. Define orthostatic (postural) hypotension and the readings that confirm it.

   A drop of >=20 mmHg systolic or >=10 mmHg diastolic (or HR rise >20) within 3 minutes of standing.

9. What is pulse pressure, and what does a narrowing pulse pressure suggest?

   Pulse pressure = systolic minus diastolic; narrowing can indicate shock, cardiac tamponade, or decreased stroke volume.

10. What early signs distinguish compensated (early) shock from late shock?

    Early shock: tachycardia, restlessness, cool clammy skin with normal-to-slightly-low BP; late shock: hypotension, bradycardia, and decreased urine output.

11. What does each wave/interval in a normal ECG represent (P, QRS, T)?

    P wave = atrial depolarization; QRS = ventricular depolarization; T wave = ventricular repolarization.

12. What are the normal durations of the PR interval and QRS complex?

    PR interval 0.12–0.20 sec; QRS complex <0.12 sec (under 3 small boxes).

13. How is ventricular fibrillation recognized on ECG, and what is the priority intervention?

    Chaotic, irregular waveform with no identifiable QRS; priority is immediate defibrillation and CPR—it is a pulseless, lethal rhythm.

14. How is ventricular tachycardia identified, and what does treatment depend on?

    Wide, regular QRS complexes at a fast rate (>100); treatment depends on pulse—defibrillate if pulseless, antiarrhythmics/cardioversion if pulse present.

15. How is atrial fibrillation identified on ECG, and what is its main complication?

    Irregularly irregular rhythm with no discernible P waves; main risk is thrombus formation and embolic stroke, so anticoagulation is needed.

16. How is asystole confirmed and treated?

    Flat line with no electrical activity; confirm in two leads, give CPR and epinephrine—asystole is NOT shockable (do not defibrillate).

17. What ECG change is the hallmark of acute myocardial injury (STEMI)?

    ST-segment elevation in contiguous leads; ST depression and T-wave inversion indicate ischemia.

18. What are the essential components of the preoperative surgical checklist/verification?

    Verify signed informed consent, confirm NPO status, correct site marking, allergies, baseline labs/vitals, and remove jewelry/dentures/prostheses.

19. Whose responsibility is obtaining informed consent, and what is the nurse's role?

    The surgeon/provider obtains informed consent; the nurse witnesses the signature and verifies the patient understands, but does not explain the procedure itself.

20. What is the priority nursing focus in the immediate postoperative (PACU) phase?

    Airway and breathing first (patent airway, oxygenation), then circulation, level of consciousness, and surgical site/bleeding.

21. What postoperative interventions prevent venous thromboembolism (DVT/PE)?

    Early ambulation, sequential compression devices, leg exercises, adequate hydration, and prophylactic anticoagulants.

22. Describe the phases of wound healing and the difference between primary and secondary intention.

    Phases: hemostasis, inflammatory, proliferative, maturation. Primary intention = clean approximated edges (sutured); secondary intention = open wound healing by granulation, slower with more scarring.

23. What are the priority nursing actions if surgical wound dehiscence or evisceration occurs?

    Cover the wound with sterile saline-soaked gauze, position supine with knees bent (low-Fowler), keep NPO, and notify the surgeon immediately—it is a surgical emergency.

24. How should a chest tube be managed, and what finding requires immediate action?

    Keep the drainage system below chest level and upright; continuous bubbling in the water-seal chamber signals an air leak, and sudden cessation of tidal fluctuation may mean obstruction. Never clamp without an order.

What this deck covers

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