Nursing Fundamentals & Assessment Master Review

4 Domains of Critical Thinking

Elements of thought, abilities, affective dimensions, intellectual standards.

Medical Asepsis vs Surgical Asepsis

Medical is clean (disinfected); Surgical is sterile (sterilization).

Hand Hygiene Requirements

Soap & water for visible soil or C. diff; alcohol hand sanitizer for general use.

Contact Precautions

Used for MRSA, VRE, scabies, herpes; requires gown and gloves.

Contact Plus Precautions

Used for C. diff; requires gown, gloves, and hand washing with soap and water.

Droplet Precautions

Used for flu, mumps, rubella, strep; requires surgical mask.

Airborne Precautions

Used for TB, varicella (chickenpox), rubeola (measles); requires N95 mask and negative pressure room.

Protective Isolation

For immunosuppressed patients; mask, meticulous handwashing, no live plants, flowers, or raw foods.

Chain of Infection

Infectious Agent, Source, Portal of Exit, Mode of Transmission, Portal of Entry, Susceptible Host.

Primary Health Promotion

Interventions implemented before disease occurs (e.g., vaccines, health education).

Secondary Health Promotion

Screening and early detection to catch disease early (e.g., mammogram, Pap smear).

Tertiary Health Promotion

Managing established disease to prevent further disability or deterioration.

Social Determinants of Health

Healthcare access/quality, neighborhood environment, social context, economic stability, education access/quality.

Vital Signs Trend in Sepsis

Vital signs increase initially, then plummet as shock develops.

Order of Physical Assessment (General)

Inspection, Palpation, Percussion, Auscultation.

Order of Abdominal Assessment

Inspection, Auscultation, Percussion, Palpation (to avoid altering bowel sounds).

Focused Health Assessment

Targeted assessment used in emergency or urgent care settings.

Episodic Assessment

Routine follow-up assessment for a known chronic condition.

Normal Body Temperature Range

97.6°F to 99.6°F (98.6°F average oral).

Most Accurate Temperature Route

Rectal temperature.

Pediatric Tympanic Temperature Technique

Pull the pinna down and back for young children.

Normal Adult Heart Rate

60 to 100 beats per minute.

Normal Adult Respiratory Rate

12 to 20 breaths per minute.

Blood Pressure Classification: Normal

Less than 120/80 mmHg

Blood Pressure Classification: Elevated

Systolic: 120-129 mmHg ; Diastolic: less than 80 mmHg

Blood Pressure Classification: Stage 1 Hypertension

Systolic 130-139 OR Diastolic 80-89 mmHg.

Blood Pressure Classification: Stage 2 Hypertension

Systolic ≥140 OR Diastolic ≥90 mmHg.

Blood Pressure Classification: Hypertensive Crisis

Systolic >180 AND/OR Diastolic >120 mmHg.

Korotkoff Sound Phases 1 and 5

Phase 1 is tapping (Systolic BP); Phase 5 is silence (Diastolic BP).

Action for Irregular Radial Pulse

Auscultate the apical pulse for 1 full minute.

Carotid Pulse Safety Rule

Never palpate both carotid arteries simultaneously to prevent syncope.

Normal Adult O2 Saturation

95% to 100% (90% to 100% acceptable in hospital settings).

Orthostatic Hypotension Definition

Drop of ≥20 mmHg systolic or ≥10 mmHg diastolic within 3 minutes of standing.

Blood Pressure Cuff Sizing Error

Too small causes falsely elevated BP; too large causes falsely low BP.

Visceral Pain

Deep organ pain (e.g., appendicitis, gallstones).

Somatic Pain

Pain originating from skin, bone, muscle, or soft tissue (e.g., bone fracture).

Radiating Pain

Pain that travels from the origin site to nearby areas (e.g., heart attack pain down arm).

Referred Pain

Pain felt in an area distant from its organ origin (e.g., shoulder pain from laparoscopic surgery).

Neuropathic Pain

Pain from nerve damage, described as burning or tingling (e.g., diabetic neuropathy).

COLDSPA Acronym

Character, Onset, Location, Duration, Severity, Pattern, Associated factors.

PQRST Acronym

Provocation, Quality, Region, Severity, Timing.

Reassessment Time: IV / Sublingual Meds

Reassess pain within 15 to 30 minutes.

Reassessment Time: Oral (PO) / IM Meds

Reassess pain within 30 to 60 minutes.

General Survey Components

First impression: age, race, sex, dress, posture, gait, orientation, facial symmetry, skin status.

Normal Capillary Refill Time

Less than 2 seconds.

Pulse Grading Scale

0 = Absent, 1+ = Diminished, 2+ = Normal, 3+ = Bounding.

Reflex Grading Scale

0 = No response, 1+ = Sluggish, 2+ = Normal, 3+ = Brisker than average, 4+ = Very brisk/hyperactive.

Order of 12 Cranial Nerves

Olfactory, Optic, Oculomotor, Trochlear, Trigeminal, Abducens, Facial, Vestibulocochlear, Glossopharyngeal, Vagus, Accessory, Hypoglossal.

Normal Tympanic Membrane Appearance

Pearly grey, shiny, and translucent.

SBAR Communication

Situation, Background, Assessment, Recommendation.

HIPAA Standard for Screen Security

Log off or lock computer terminals when stepping away from the desk.

ADPIE Nursing Process

Assessment, Diagnosis, Planning, Implementation, Evaluation.

SMART Goals in Nursing Planning

Specific, Measurable, Attainable, Realistic, Time-limited.

Autonomy

Supporting a patient's right to make their own informed decisions.

Beneficence

Actions taken to promote the good and well-being of others.

Nonmaleficence

The ethical duty to do no harm.

Veracity

The obligation to tell the truth.

Justice

Fair and equitable treatment for all patients.

Fidelity

Keeping promises and commitments made to patients.

Trendelenburg Position

Head down, feet elevated; used to increase venous return during shock.

Semi-Fowler's Position

Head of bed elevated 30 to 45 degrees; prevents aspiration during tube feedings.

Side Rails Safety Rule

Using 4 side rails up is legally considered a restraint.

Restraint Care Requirements

Requires order renewal every 24 hours; assessment and neurovascular check every 2 hours.

Primary Bacterial Cause of UTIs

Escherichia coli (E. coli) from fecal contamination.

Unconscious Oral Hygiene Position

Side-lying (Sims) position with suction equipment prepared.

Skin Turgor Locations & Signs

Tested on forearm or clavicle; tenting indicates dehydration.

Hydration & Kidney Function Labs

Blood Urea Nitrogen (BUN) and Serum Creatinine.

Normal Serum Creatinine Range

0.6-1.2 mg/dL for females; 0.8-1.4 mg/dL for males.

Normal BUN Range

7 to 20 mg/dL.

Nail Clubbing Significance

Nail angle ≥180 degrees; indicates chronic hypoxia (e.g., COPD).

Braden Scale Categories

Sensory perception, moisture, activity, mobility, nutrition, friction/shear (lower score = higher risk).

Macule vs Patch

Macule is flat

Papule vs Plaque

Papule is elevated solid

Vesicle vs Bulla

Vesicle is fluid-filled

Stage 1 Pressure Injury

Intact skin with localized non-blanchable erythema.

Sterile Field Handling Rules

Never turn back to field, keep hands above waist, open top package flap away from you.

Types of Urinary Incontinence

Stress (exertion), Urge (sudden desperate need), Functional (mobility barrier), Overflow (dribbling/retention).

Indwelling Catheter Placement Level

Always maintain the drainage bag below bladder level.

Assault vs Battery

Assault is the threat of force; Battery is unconsented physical touching or action.

Libel vs Slander

Libel is written defamation; Slander is spoken defamation.

4 Ds of Negligence

Duty, Dereliction, Direct Cause, Damages.

Normal Hemoglobin Levels

11 to 15 g/dL.

Normal Albumin Level

3.5 g/dL or higher.

7 F's of Abdominal Distention

Fat, Fluid, Fetus, Flatus, Fibroid, Feces, Fatal growth.

Confirming Nasogastric (NG) Tube Placement

Radiographic X-ray is the gold standard (pH testing

Lymph Node Normal Findings

Movable, discrete, soft, and non-tender.

PERRLA Acronym

Pupils Equal, Round, Reactive to Light, and Accommodation.

Accommodation Test Reaction

Pupils constrict and eyes converge when focusing on an approaching object.

Snellen Chart Function

Measures distant visual acuity.

Confrontation Test Function

Measures peripheral vision fields.

Romberg Test Procedure & Result

Stand feet together, eyes closed for 20s; negative test is minimal swaying.

Rinne Test Normal Finding

Air Conduction (AC) is twice as long as Bone Conduction (BC) [AC > BC].

Types of Headaches

Sinus (pressure/throbbing), Tension (hatband pressure), Cluster (intense orbital stabbing), Migraine (throbbing with aura/photophobia).

Signs of IV Phlebitis

Redness, warmth, tenderness, and a palpable venous cord; treat with warm compress.

Infiltration vs Extravasation

Infiltration is non-vesicant fluid leakage (cool/edematous); Extravasation is vesicant leakage causing tissue necrosis.

Osteoarthritis vs Rheumatoid Arthritis

Osteoarthritis is non-inflammatory unilateral wear/tear; Rheumatoid is bilateral autoimmune inflammation with morning stiffness.

Gout Pathophysiology & Key Site

Uric acid crystal deposition; commonly presents in the metatarsophalangeal joint of the big toe.

Phalen Test & Tinel Sign

Diagnostic physical assessments for Carpal Tunnel Syndrome.

Cane Walking Technique

Hold cane on stronger side; move cane first, then weaker leg, then stronger leg.

Crutch Stairs Rule

Ascend with the good leg first ('up with the good'); descend with the bad leg first ('down with the bad').