Free ANCC MEDSURG-BC Exam Flashcards

Begin with an open invitation that lets the patient identify priorities, then use focused questions to clarify onset, course, associated findings, risks, and functional impact without losing the patient's main concern.

The patient is the primary source. Family, caregivers, records, and other clinicians are secondary sources used to supplement or verify information, with consent and privacy protections as applicable.

Prescription drugs, over-the-counter products, vitamins, herbals, supplements, recent changes, actual use, allergies and reactions, and the patient's ability to obtain and take each product safely.

Onset, provoking or palliating factors, quality, region or radiation, severity, and timing. It structures symptom detail but does not replace a complete assessment or urgent stabilization.

The abdomen is generally inspected and auscultated before percussion and palpation because touching the abdomen can alter bowel sounds and distort the baseline finding.

A trend shows direction and rate of change relative to the patient's baseline. An apparently acceptable single value can hide deterioration, while an unusual baseline may be stable for that patient.

ADLs are basic self-care functions such as bathing, dressing, toileting, transferring, and eating. IADLs support independent community living, such as managing medications, money, meals, transport, and shopping.

A new decline in alertness, orientation, speech, pupils, strength, or behavior can signal evolving compromise. Compare with the documented baseline, assess promptly, and escalate unexpected change.

Delirium is typically acute, fluctuating, and marked by impaired attention; dementia is usually chronic and progressive. A sudden cognitive change should be treated as a possible acute clinical problem, not assumed to be dementia.

Ask directly and calmly about thoughts, intent, plan, means, and past behavior, then act on the level of immediate risk. Direct questioning supports disclosure and does not create suicidal intent.

Interview the patient privately, use neutral and nonjudgmental language, use a qualified interpreter when needed, assess immediate danger, and follow applicable reporting and safety procedures.

Use matter-of-fact, non-stigmatizing questions about substance, amount, frequency, last use, withdrawal history, consequences, and readiness for help. Explain why the information affects safe care.

Confirm the correct patient and result, promptly assess the patient, follow the critical-result policy, notify the appropriate clinician, initiate authorized urgent measures, and document the response without delaying emergency care.

Verify the order, patient identity, indication, required preparation, allergies and medication considerations, relevant baseline data, consent status when applicable, and the plan for monitoring and follow-up.

A medical diagnosis identifies a disease or pathology. A nursing diagnosis describes a patient response or risk that nursing assessment, intervention, and evaluation can address.

Address immediate threats to airway, breathing, circulation, safety, or rapidly worsening function before stable longer-term needs, while considering the patient's goals and the actual clinical context.

A problem-focused diagnosis is supported by current defining characteristics. A risk diagnosis identifies susceptibility before the problem develops, so it is supported by risk factors rather than current signs and symptoms.

Sodium concentration reflects water balance and influences fluid shifts across cell membranes. Rapid or severe shifts can change brain-cell volume, so mental-status and neurologic changes require prompt attention.

Potassium is central to cardiac conduction and skeletal-muscle and nerve function. An abnormal result should be interpreted with symptoms, rhythm findings, renal function, medications, and the overall clinical picture.

Deficit tends toward reduced perfusion, dry mucosa, low urine output, and weight loss; excess tends toward edema, congestion, rising weight, and respiratory findings. Trends and comorbidities are more reliable than one sign alone.

It is patient-centered, specific, measurable, realistic, relevant to the identified problem, and linked to a time frame so the nurse can determine whether care worked.

The intervention should address a contributing factor, reduce risk, or move the patient toward the stated outcome. A routine action without a clear link is not individualized planning.

Reassess the patient and diagnosis, determine whether the intervention was performed and effective, identify barriers or new data, and revise the plan rather than simply repeating ineffective care.

Increasing drainage or swelling, tachycardia, falling blood pressure, pallor, restlessness, reduced urine output, or worsening weakness can indicate blood loss. Assess the patient and operative site and escalate promptly.

Positioning, deep breathing and coughing, prescribed lung-expansion exercises, adequate pain control, and early mobilization support ventilation and secretion clearance; reassess tolerance and respiratory status.

Use the ordered mechanical and pharmacologic measures, encourage safe early mobility and leg movement, maintain hydration when appropriate, and monitor for bleeding as well as new thromboembolic symptoms.

Assess systemic and local findings, review trends and devices, obtain ordered specimens correctly, use infection-prevention measures, communicate deterioration promptly, and evaluate response to the treatment plan.

It checks how clearly the nurse explained—not whether the patient can repeat memorized words. Ask the patient to explain or demonstrate the plan in their own way, then reteach and reassess gaps.

Assess readiness, goals, baseline knowledge, preferred language and format, literacy and sensory needs, culture, cognition, emotional state, physical comfort, and barriers to carrying out the plan.

A qualified interpreter supports accurate, impartial, and confidential communication. Do not require a patient to supply an interpreter or rely on an unqualified person; an informed adult may decline the offered service and request an adult companion when law, policy, competence, and confidentiality allow.

Explain what to do, how and when to do it, expected effects, warning signs, whom to contact, follow-up plans, and how to obtain medicines, equipment, transport, and other needed resources.

Fall risk arises from different combinations of mobility, cognition, continence, medications, vision, equipment, environment, and prior falls. Match interventions to the patient's actual risks and reassess after changes.

Use restraint only for a justified safety need after less restrictive interventions are ineffective, then select the least restrictive effective form. Follow authorization and monitoring requirements, meet basic needs, reassess, and discontinue at the earliest safe time.

Assess the patient first, then identify the alarm's cause, verify connections and settings against the plan, correct the problem, and confirm that monitoring is functioning. Never treat the sound alone.

At admission, transfer between settings or levels of care, and discharge. Compare the best available medication history with new orders and resolve omissions, duplications, interactions, and unintended changes.

A predictable nonallergic effect follows the drug's pharmacology, while a drug allergy is an immune-mediated hypersensitivity reaction. Document the drug, reaction, timing, and severity instead of using an unsupported label that can distort future treatment.

Risk depends on indication, duplication, interactions, organ function, adherence, prescribers, and patient goals. Reconcile every product and identify medicines that may be unnecessary, unsafe, or difficult to use.

Match options such as positioning, relaxation, heat or cold when appropriate, distraction, and environmental changes to the patient's condition and preferences, then evaluate benefit and safety alongside prescribed treatment.

Ask what the patient actually uses and check for interactions, contraindications, duplicate effects, product variability, and procedure-related risks. 'Natural' does not automatically mean harmless.

Use current guidance together with age, history, risk, access, readiness, culture, goals, and preferences. Support informed, achievable changes and evaluate follow-through rather than delivering a generic checklist.

It invites the patient to choose what matters and provide context: 'What concerns you most about going home?' usually yields more useful information than a question answerable only by yes or no.

Validation acknowledges the person's experience—'This uncertainty sounds frightening'—without confirming an inaccurate belief or promising an outcome the nurse cannot guarantee.

Recognize personal assumptions, ask rather than presume, listen to the patient's own values and practices, address power differences, and adapt care collaboratively without stereotyping a group.

Ask the patient whom to involve and what may be shared, protect confidentiality, include chosen supports, and keep the capable patient's goals and decisions central even when relatives disagree.

Consider the task, patient circumstances and stability, delegatee's authorized role and verified competence, clarity of directions and reporting limits, and the supervision and evaluation the RN can provide.

The RN remains accountable for the decision to delegate, appropriate instructions and supervision, follow-up on reported data, and evaluation of the patient's response; delegation does not transfer nursing judgment.

Consult when the patient needs another discipline's distinct expertise, such as swallowing, mobility, medication, nutrition, or resource assessment. Delegation instead authorizes performance of a nursing-related task within defined limits.

Assess understanding and voluntariness, ensure questions are answered, communicate the decision, document appropriately, and support the patient's right to decide without coercion while continuing safe care.

P defines the patient or problem, I the intervention or exposure, C the comparison, and O the measurable outcome. A focused PICO structure guides an efficient evidence search.

Appraise study quality, consistency, effect size, harms, population fit, feasibility, clinical expertise, and patient preferences; after implementation, measure outcomes and unintended effects.