← Med-Surg Priorities: NCLEX-RN Flashcards

NCLEX-RN Nursing Exam Study Guide

Key concepts, definitions, and exam tips organized by topic.

36 cards covered

Med-Surg Priorities: NCLEX-RN Study Guide


Overview

Medical-surgical nursing requires rapid clinical decision-making based on systematic prioritization frameworks. This guide covers the essential priority concepts tested on the NCLEX-RN, focusing on life-threatening complications, time-sensitive interventions, and safe nursing practice. Mastery of ABC prioritization, delegation principles, and recognition of clinical deterioration is critical for exam success.


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Airway & Respiratory Priorities


Key Concepts

Airway and breathing always take top priority in nursing care. Recognizing early signs of respiratory compromise and knowing when to escalate are essential NCLEX competencies.


Critical Scenarios & Interventions


  • • Post-thyroidectomy stridor → Signs of laryngeal edema or tracheal hematoma; notify surgeon immediately and prepare for emergency airway management
  • • COPD exacerbation with SpO₂ 88% → Target 88–92% to avoid suppressing the hypoxic drive (COPD patients rely on low O₂, not high CO₂, to breathe)
  • • Post-bronchoscopy oral intake → Always assess gag reflex return before allowing any oral intake; throat is anesthetized during procedure
  • • Chest tube — stopped tidaling → Either lung has re-expanded (expected) OR tube is kinked/obstructed (must rule out); assess tube patency first
  • • Pulmonary embolism → SpO₂ <90% + tachycardia + hypotension = massive PE = hemodynamic emergency

    • Key Terms

  • • Hypoxic drive: The mechanism by which low PaO₂ (rather than high PaCO₂) stimulates breathing in chronic CO₂ retainers
  • • Tidaling: Normal rise and fall of fluid in the water-seal chamber with respiration, confirming chest tube patency
  • • Stridor: High-pitched inspiratory sound indicating upper airway obstruction

    • Watch Out For

    > ⚠️ COPD Oxygen Trap: Do NOT target normal SpO₂ (95–100%) in COPD patients — this suppresses their hypoxic drive and can cause respiratory arrest. Target 88–92% only.

    >

    > ⚠️ Tidaling vs. Bubbling: Stopped tidaling ≠ always bad. Bubbling in the water-seal chamber, however, may indicate an air leak. Know the difference.


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    Post-Operative Care Priorities


    Key Concepts

    Post-operative complications often present with subtle early signs. Nurses must recognize patterns that indicate surgical emergencies and act within critical time windows.


    Critical Scenarios & Interventions


    | Finding | Suspected Complication | Priority Action |

    |---|---|---|

    | Urine output <30 mL/hr × 2 hrs | Oliguria / hypovolemia / AKI | Notify provider immediately |

    | Rigid abdomen + fever after bowel resection | Anastomotic dehiscence / peritonitis | Immediate MD notification, OR prep |

    | Shortened, internally rotated leg post-THR | Hip dislocation | Notify surgeon immediately |

    | Chills + flank pain + dark urine during transfusion | Acute hemolytic reaction | STOP transfusion immediately; maintain IV with NS |

    | Patient unconscious post-surgery | Airway protection risk | Lateral (recovery) position |


    Key Terms

  • • Anastomotic dehiscence: Breakdown of a surgical bowel connection, leading to peritonitis
  • • Acute hemolytic transfusion reaction: ABO incompatibility causing RBC destruction; can be fatal if transfusion continues
  • • Oliguria: Urine output <30 mL/hr (adult); indicates renal or hemodynamic compromise

    • Watch Out For

    > ⚠️ Transfusion Reaction Priority: Always STOP the transfusion FIRST, then maintain IV access with normal saline (not the existing line). Never restart blood through the same tubing.

    >

    > ⚠️ THR Rotation: Internal rotation = dislocation. External rotation restrictions apply before dislocation occurs. Post-dislocation: do NOT attempt to reposition; notify surgeon.


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    Fluid, Electrolyte & Hemodynamic Priorities


    Key Concepts

    Electrolyte imbalances and hemodynamic instability are frequently tested because they affect cardiac rhythm and organ perfusion. Know the "danger zones" for each electrolyte.


    Critical Electrolyte Priorities


    #### Hypokalemia (furosemide/loop diuretics)

  • • Loop diuretics cause potassium wasting → risk of fatal dysrhythmias
  • • Monitor ECG: flat T waves, U waves
  • • Replace potassium as ordered; never give IV K⁺ as a bolus

    • #### Hyperkalemia

  • • Earliest ECG sign: Peaked (tall, tent-shaped) T waves
  • • Progression: widened QRS → sine wave pattern → ventricular fibrillation
  • • Emergency treatment: calcium gluconate (cardiac protection), then sodium bicarbonate, insulin + dextrose, kayexalate

    • #### Hyponatremia (SIADH)

  • • Serum Na⁺ <118 mEq/L with seizures/confusion → hypertonic saline (3% NaCl)
  • • Correct no faster than 1–2 mEq/L/hr to prevent osmotic demyelination syndrome (ODS)

    • Critical Hemodynamic Scenarios


  • • Hypovolemic shock (BP 80/50, HR 130, cool/clammy) → Isotonic crystalloids first (0.9% NS or Lactated Ringer's)
  • • TPN abruptly discontinued → Infuse D10W to prevent rebound hypoglycemia
  • • CKD + hyperphosphatemia (PO₄ 7.2) → Restrict dairy, nuts, cola, processed foods

    • Key Terms

  • • SIADH: Syndrome of Inappropriate Antidiuretic Hormone — excessive water retention causing dilutional hyponatremia
  • • Osmotic demyelination syndrome: Irreversible neurological damage from too-rapid sodium correction
  • • Third-spacing: Fluid shifts into non-functional compartments (e.g., peritoneum in pancreatitis), causing intravascular hypovolemia

    • Watch Out For

    > ⚠️ TPN Discontinuation: Never abruptly stop TPN without a bridge infusion. The pancreas continues secreting insulin → hypoglycemia. Always use D10W as a temporary replacement.

    >

    > ⚠️ Sodium Correction Speed: Correcting hyponatremia too fast is as dangerous as the hyponatremia itself. Slower is safer — target ≤12 mEq/L in 24 hours.


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    Neurological & Endocrine Priorities


    Key Concepts

    Neurological deterioration can be rapid and irreversible. Endocrine crises are often missed because symptoms mimic other conditions. Early recognition and escalation are critical.


    Critical Scenarios & Interventions


    #### Neurological

  • • Declining GCS (13 → 9) in head injury → Indicates rising ICP; notify provider immediately
  • • Post-pituitary surgery: Clear nasal drainage + glucose positive = CSF leak → urgent MD notification (meningitis risk)

    • #### Endocrine

  • • Diabetes insipidus: Urine output 600 mL/hr + specific gravity 1.001 (dilute) → IV fluid replacement + desmopressin (DDAVP)
  • • Addisonian crisis: Hypotension + hyponatremia + weakness → Priority treatment: IV hydrocortisone

    • Myasthenia Gravis Crisis Differentiation


    | Feature | Myasthenic Crisis | Cholinergic Crisis |

    |---|---|---|

    | Cause | Too little medication | Too much medication |

    | Weakness | ✓ Yes | ✓ Yes |

    | SLUDGE symptoms | ✗ No | ✓ Yes |

    | Treatment | Increase anticholinesterase | Stop anticholinesterase; atropine |


    SLUDGE: Salivation, Lacrimation, Urination, Defecation, GI distress, Emesis


    Key Terms

  • • Glasgow Coma Scale (GCS): Neurological assessment tool (3–15); score ≤8 indicates severe impairment
  • • Diabetes insipidus (DI): Deficiency of ADH causing massive dilute urine output; specific gravity 1.001–1.005
  • • Addisonian crisis: Acute adrenal insufficiency; life-threatening without immediate glucocorticoid replacement

    • Watch Out For

    > ⚠️ CSF Leak Test: Clear nasal drainage post-pituitary surgery should be tested with a glucose strip. CSF is glucose-positive; mucus is not. This is a surgical emergency.

    >

    > ⚠️ DI vs. SIADH: These are opposites. DI = massive dilute urine (low specific gravity). SIADH = concentrated urine, water retention, low serum sodium. Do not confuse them.


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    Cardiac & Vascular Priorities


    Key Concepts

    Cardiac emergencies require instant recognition and action. Time-sensitive interventions (PCI within 90 minutes) and recognition of life-threatening rhythms and complications are top NCLEX priorities.


    Critical Scenarios & Interventions


    #### Acute MI

  • • Crushing chest pain + radiation + diaphoresis → 12-lead ECG immediately
  • • STEMI: Primary PCI within 90 minutes of first medical contact
  • • NSTEMI: Medical management (anticoagulation, antiplatelet therapy)

    • #### Cardiac Tamponade — Beck's Triad

    1. Muffled heart sounds

    2. Jugular venous distension (JVD)

    3. Hypotension

  • • Plus pulsus paradoxus >10 mmHg
  • • Treatment: Pericardiocentesis (emergency needle drainage)

    • #### AAA Rupture

  • • Severe tearing back/abdominal pain + hypotension + pulsatile mass → Emergency surgery; mortality extremely high

    • #### Medication Toxicities


    | Drug | Toxic Signs | Priority Action |

    |---|---|---|

    | Digoxin | Nausea, yellow-green halos, HR <60 | Hold dose; notify provider; check serum level |

    | Heparin (IV) | aPTT >100 sec (therapeutic 60–100) | Hold infusion; notify provider |


    Key Terms

  • • STEMI: ST-Elevation Myocardial Infarction — complete coronary artery occlusion
  • • Pulsus paradoxus: Drop in systolic BP >10 mmHg during inspiration; classic sign of tamponade
  • • aPTT: Activated Partial Thromboplastin Time — monitors heparin therapy (therapeutic: 60–100 seconds)

    • Watch Out For

    > ⚠️ Digoxin + Hypokalemia: Hypokalemia potentiates digoxin toxicity. Always check potassium levels in patients on both digoxin and diuretics — this is a high-yield NCLEX combination.

    >

    > ⚠️ 12-Lead ECG First for Chest Pain: Before nitroglycerin, before morphine — the ECG comes first to identify STEMI and guide reperfusion decisions.


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    GI, GU & Integumentary Priorities


    Key Concepts

    GI emergencies often involve rapid fluid loss and hemorrhage. Burn care requires precise fluid calculations. Infection recognition and prevention are key integumentary priorities.


    Critical Scenarios & Interventions


    #### GI Emergencies

  • • Cirrhosis + bright red vomiting = variceal hemorrhage → Large-bore IV access + fluid/blood resuscitation immediately
  • • Pancreatitis with hematocrit 52% = Third-spacing + hemoconcentration → Aggressive IV fluid resuscitation
  • • Post-appendectomy fever + rigidity + absent bowel sounds = Peritonitis → Notify MD; surgical re-exploration likely

    • #### Burn Care — Parkland Formula

    > Parkland Formula: 4 mL × weight (kg) × % TBSA burned = Total 24-hour fluid volume (Lactated Ringer's)


  • • First 8 hours: Give ½ of total volume (calculated from time of injury, not admission)
  • • Next 16 hours: Give remaining ½ of total volume

    • #### CAUTI (Catheter-Associated UTI)

  • • Fever + CVA tenderness + cloudy/malodorous urine → Culture and sensitivity FIRST, then antibiotics

    • Key Terms

  • • Esophageal varices: Dilated veins in the esophagus from portal hypertension in cirrhosis; rupture causes massive hemorrhage
  • • TBSA: Total Body Surface Area — used in burn calculations
  • • CAUTI: Catheter-Associated Urinary Tract Infection — most common hospital-acquired infection
  • • CVA tenderness: Costovertebral angle tenderness; indicates renal/kidney involvement

    • Watch Out For

    > ⚠️ Parkland Formula Timing: The 8-hour clock starts from the time of the burn injury, not the time the patient arrives at the hospital. If 2 hours have already passed, the first half must be given in the remaining 6 hours.

    >

    > ⚠️ Culture Before Antibiotics: Always obtain cultures before starting antibiotics to ensure accurate sensitivity results. This applies to UTIs, wound infections, and sepsis workups.


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    Safety, Prioritization & Delegation


    Key Concepts

    NCLEX heavily tests the nurse's ability to prioritize, delegate appropriately, and recognize safety-critical situations. Know what UAPs can and cannot do.


    Prioritization Frameworks


    #### ABC Priority Order

    1. Airway

    2. Breathing

    3. Circulation

    4. Everything else (pain, psychosocial, education)


    #### Maslow's Hierarchy (applied to nursing)

  • • Physiological needs → Safety → Psychosocial → Self-actualization

    • #### Priority "Red Flags" — Assess These Patients First

  • • New onset dyspnea or stridor
  • • SpO₂ <90%
  • • Patient states "something opened up inside" (possible internal hemorrhage)
  • • Sudden hemodynamic instability

    • Delegation Guidelines


    | Can Delegate to UAP | Cannot Delegate to UAP |

    |---|---|

    | Vital signs on stable patients | Initial assessment/nursing judgment |

    | Assisting with ADLs (bathing, feeding) | Medication administration |

    | Measuring I&O | IV insertion or care |

    | Ambulating stable patients | Patient teaching |

    | Collecting non-invasive specimens | Interpreting data/findings |


    Medication Safety — Red Man Syndrome

  • • Vancomycin given too rapidly → Flushing, erythema, hypotension of neck/chest
  • • Action: Slow or stop infusion; administer over at least 60 minutes; may give diphenhydramine
  • • This is NOT a true allergic reaction — it is a rate-related reaction

    • Discharge Teaching — Know What's Expected vs. Concerning


    | Expected (do NOT call MD) | Report to MD |

    |---|---|

    | Shoulder pain post-laparoscopic surgery (CO₂ irritation, resolves in 24–48 hrs) | Persistent or worsening shoulder pain beyond 48 hrs |

    | Mild incisional pain | Signs of wound infection (redness, drainage, fever) |

    | Fatigue after surgery | Sudden severe pain, bleeding, or fever |


    Watch Out For

    > ⚠️ Delegation ≠ Abandonment of Responsibility: The nurse delegates tasks, but retains accountability for the outcome. Always follow up on delegated tasks.

    >

    > ⚠️ Red Man Syndrome vs. Anaphylaxis: Red Man is rate-related (slow the infusion). Anaphylaxis requires epinephrine and stopping the drug permanently. Know the difference.

    >

    > ⚠️ "Assess First" Trap: On NCLEX, "notify the provider" is only correct after you've confirmed the finding is serious. For unstable patients, assess first — but for clear emergencies (transfusion reaction, rupt

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