Fundamentals / Safety NCLEX Clinical Study Booklet · 10 cards
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Prioritization. Prioritization Frameworks (in order)
ABCs: Airway → Breathing → Circulation Maslow: physiologic before psychosocial Acute/unstable before chronic/stable Nursing process: assess before intervening (unless ABC emergency) 'Which client first?'
Choose unstable, new, or unexpected findings Airway/breathing threats first Chronic / stable / expected can wait Tips
Absolutes ('always/never') are often wrong When unsure, assess first NCLEX Tip Prioritize with ABCs, then Maslow, then acute-over-chronic. 'See first' = the unstable client or one with a new or unexpected change.
Delegation. Delegation RN Only
Assessment, planning, evaluation, teaching Unstable clients, IV push meds, blood administration First assessment / admission LPN / LVN
Stable clients with predictable outcomes Reinforcing teaching; many meds (not usually IV push) Routine skills (dressings, catheters, tube feeds) UAP
ADLs, hygiene, feeding (stable), vital signs (stable) Ambulation, positioning, I&O, specimen collection Does NOT assess, teach, or use clinical judgment NCLEX Tip Delegate stable, routine, predictable tasks. Anything requiring assessment, teaching, evaluation, or an unstable client stays with the RN.
Infection Control. Infection Standard Precautions
Apply to ALL clients Hand hygiene; gloves / PPE for body-fluid contact PPE Order
Donning: gown → mask → goggles → gloves Doffing: gloves → goggles → gown → mask (mask last, outside room) Hand Hygiene
#1 way to prevent infection Soap & water for C. diff, norovirus, visible soil Alcohol rub otherwise NCLEX Tip Hand hygiene is the #1 infection-control measure. Don PPE gown→mask→goggles→gloves; doff gloves→goggles→gown→mask.
Restraints & Fall Prevention. Safety Fall Prevention
Bed low & locked, call light in reach Non-skid footwear, lighting, clear path Fall-risk assessment; hourly rounding Restraints
Last resort, least restrictive Provider order (time-limited, not PRN) Monitor circulation, skin, ROM; offer toileting / food / water Safety
Quick-release ties to the bed frame (not side rails) Continuous monitoring; document NCLEX Tip Restraints are a last resort needing a time-limited provider order. Tie to the bed frame with quick-release knots and monitor circulation and skin.
Positioning Quick Reference. Safety Neuro / Respiratory
↑ICP: HOB 30°, head midline Dyspnea / left-sided HF: high Fowler's After lumbar puncture: flat / supine Emergencies
Air embolism: left lateral + Trendelenburg Autonomic dysreflexia: high Fowler's (sit up) Shock: legs elevated (modified Trendelenburg) Other
Post-tonsillectomy / unconscious: side-lying Pregnant (vena cava): left lateral After liver biopsy: right side-lying NCLEX Tip Know the classics: ↑ICP → HOB 30° midline; air embolism → left side + Trendelenburg; unconscious → side-lying to prevent aspiration.
Legal & Ethical. Legal Informed Consent
Provider obtains it; nurse WITNESSES the signature Client must be competent and un-sedated Confirm understanding Client Rights
Advance directives / DNR — honor wishes HIPAA: minimum necessary disclosure Right to refuse treatment Mandatory Reporting
Abuse (child, elder, vulnerable adult) Certain communicable diseases NCLEX Tip The provider obtains informed consent; the nurse witnesses the signature and confirms understanding. A sedated client cannot give consent.
Rights of Medication Administration. Medication The Rights
Right patient (2 identifiers), drug, dose, route, time Right documentation, reason, response, to refuse Safety
Verify allergies every time Don't give a med you didn't prepare Question unclear or unsafe orders High-Alert
Insulin, heparin, opioids, KCl, chemo → double-check Never IV potassium push NCLEX Tip Use two identifiers and verify allergies before every medication. High-alert drugs require an independent double-check.
Vital Signs & Normal Values. Assessment Adult Normals
HR 60–100; RR 12–20 BP <120/80 (normal); Temp ~98.6°F (37°C) O₂ sat ≥95% Report If
HR <60 or >100; RR <12 or >20 BP <90 systolic or hypertensive crisis O₂ sat <90%; fever Notes
Assess trends, not just single values Pain is the '5th vital sign' (self-report) NCLEX Tip Know adult normals: HR 60–100, RR 12–20, BP <120/80, O₂ ≥95%. Report values outside safe parameters and watch trends.
Safe Handling & Body Mechanics. Safety Body Mechanics
Bend at the knees, not the waist Keep the load close; use leg muscles Avoid twisting; get help / use devices Safe Patient Handling
Use mechanical lifts / transfer aids Two-person assists for heavy / unstable clients Lock wheels before transfers Prevent Injury
Assess the client's ability before moving Communicate the plan; count together NCLEX Tip Protect your back: bend at the knees, keep the load close, avoid twisting, and use mechanical lifts or extra help for heavy transfers.
Error Reporting & Client Safety. Safety Medication Error
Assess the client FIRST (safety) Notify the provider; monitor Document facts; complete an incident report Incident Report
Factual and objective Do NOT reference it in the chart or place it in the record Used for quality improvement, not blame Culture of Safety
Report near-misses Root-cause analysis (systems focus) Never events NCLEX Tip After a medication error, assess the client first, then notify the provider and file an incident report — factual, and never referenced in the chart.
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